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Full text of "Harvard medical alumni bulletin"

AUTUMN 2005 I^^^H^^^^^^B^^H^^HH^^V' 9 




ALUMNI BULLETIN 





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Compelled by a long-held desire 
to become o surgeon, Maurice 
Richardson (pictured here circa 
1 905) joined the surgical ranks c 
Massachusetts General Hospital 
soon after graduating from HMS; 
in 1 877. His skills earned him \[ 
distinction of the Moseley Profes 
sorship of Surgery. An advocate 
of surgery as a specialty, Richarc 
son excelled in abdominal surgel 
and pioneered the development 
of the appendectomy. 



AUTUMN 2005 • \' O L U M E 79, NUMBER 2 



CO 




TF.NTS 



DEPARTMENTS 



Letters 3 

Pulse 5 

A faculty sur\'ey finds that doctors foIlov\' 
tfie advice they likely give their patients; 
the Center for the History of Medicine 
becomes a patron ol the arts; members 
of the Class of 2009 don their coats 

President's Report 7 

b\' Stcxcn A. Schrociki 

Bookmark 8 

A rc\icw by Elissa Ely of The Health Care 
of Homeless Persons 

Bookshelf 9 

Benchmarks 10 

A decrease in emergency department 
\'isits during baseball playoffs; a bacterium 
linked to neo\ascular macular degenera 
tion; the health effects of climate change; 
new findings on women's health 

Alumnus Profile 56 

Thomas J. Gill I\' puts his biomotion 
laboratory to revolutionary use for his 
newest patients: the Boston Red Sox. 
by Janice O'Leary 

Class Notes 58 

Obituaries 61 

Endnotes 64 

Expressing empathy is not just good 
manners — it's good medicine. 
by Alice Flaherty 

Cover image: Christopher Zacharow.lmagcs.com/Corhis 



SPECIAL REPORT: THE UNINSURED 



The Death Spiral 14 

Gaps in health insurance have created a new caste system in the 
United States, by rushika fernandopulle 

^ Under Covered 20 

what will It take to wake the nation up to the need for universal 
health coverage? h\ pat mccaffrey 

Preaching to the Exiles 26 

For people without health insurance, a serious illness can start a 
downward spiral that may e\'en lead to homelessness. 

h\ JAMES J. O'CONNELL 

Uncharted Waters 34 

Doctors recount their struggles and fears as they recall the dark days 
when Katrina hit home, bv a n n marie m e n t i n t. 

Freeze Frame 42 

Several risks to pediatric health arc literally staring children in the face. 
It's time to call the doctor, bv j a n i c e o • l e a r y 

White Cap 50 

Training at Harvard hospitals during World War II gave one student 
nurse a crash course in the fast paced realities of clinical care. 

bv MARTHA bears RICH 




Harvard Medina] 



ALUMNI BULLETIN 



In This Issue 




OOKING AT THE U.S. HEALTH CARE SYSTEM lODAY IS LIKE WATCHING IN 

slow motion as the wine glass teeters — ^just before it falls, spills, 
and shatters. You know what's coming and find it odd how immo- 
bilized you are when action seems imperative. In this issue of the Bulletin our 
special report is about the uninsured in the United States — a group whose 
numbers are rising as inexorably as the Gulf Coast waters did last fall. (We 
also spend some time with HMS alumni who were caught in that disaster.) 

In important ways, identifying the "uninsured" as the issue undermines our 
abihty to address it. If the problem is framed as one concerning an underprivi- 
leged group of people, then the reflex response is to adopt one of two seemingly 
opposite but ultimately similar and unproductive ways of thinking. Health care 
for the less fortunate can be seen as requiring some form of charity or welfare, 
which indicates that people of means are asked to bestow a benefit on those 
w ithout. Or it can be called a basic "right," whereupon the have-nots are seen as 
forcing the haves to yield some of their bounty. Either way, hidden in the term 
"uninsured" is an impUcit opposition between "us" and "them." When such a 
line is drawn a certain pohtical paralysis sets in, and awful gravity takes its toll. 

This rhetorical dead end does not seem inevitable, however. Without 
becoming sappy or eschewing analysis, one may recognize that lack of ade- 
quate insurance for a large fraction of the population has become everyone's 
problem. In 1953 Charles E. Wilson (often misquoted) said, "For years I 
thought what was good for our country was good for General Motors, and 
vice versa." It has become increasingly clear that a unified and universal health 
insurance plan, not tied to employment, would have been very, very good for 
General Motors. It only remains to be seen whether this country's political 
and business leadership can become capable of de\'eloping a system that is 

adequate, economical, and fair. Stay tuned, but don't hold your breath. 

* * * 

Beverly Ballaro, our associate editor for six years, has left the Bulletin to be 
with three grov\ing boys and to develop her writing gifts in other areas. She 
leaves us with warm memories and a legacy of fine articles, including those 
she wrote about HMS during World War II. This issue introduces Ann Marie 
Menting as our new associate editor. She brings a broad background in sci- 
ence journalism, and we will look to her to help us strengthen our coverage 
of science at HMS. 



EDITOR-IN-CHIEF 

William Ira Bennett '68 

EDITOR 

Paula Brewer Byron 

ASSOCIATE EDITOR 

Ann Marie Menting 

ASSISTANT EDITOR 

Janice O'Lear)- 

BOOK REVIEW EDITOR 

Elissa Hy '88 



EDITORIAL BOARD 

Judy Ann Bigby '78 

Rafael Campo '92 

Elissa Ely '88 

Daniel D. Federman '53 

Timothy G. Ferris '92 

Alice Flahert)' '94 

Atul Gawande '94 

Robert M. Goldw}!! '56 

Petri Klass '86 

Victoria McEvoy '75 

James J. O'ConneU '82 

Nancy E. Oriol '79 

Anthony S. Patton '58 

Mitchell T. Rabkin '55 

Eleanor Shore '55 



DESIGN DIRECTOR 

Laura McFadden 



^,U> 



^i IM 




ASSOCIATION OFFICERS 

Steven A. Schroeder '64, president 

A. W. Karchmer '64, president-elect 1 

W'tUiam W. Chin '72, president elect 2 

Susan M. Okie '78, \1ce president 

Rodney J. Taylor '95. secretary- 
Kathleen E. Toomey '78, treasurer 

COUNCILLORS 

Wesley A. Curry '76 

Timothy G. Ferris '92 

Gerald S. Foster '51 

Edward D. Harris, Jr. '62 

Linda S. Hotchkiss '78 

Lisa I. lerzoni '84 

Katherine A. Keeley '94 

Christopher J. O'Donnell '87 

Rachel G. Rosovsky '00 

DIRECTOR OF ALUMNI RELATIONS 

George E. Thibault '69 

REPRESENTATIVES TO THE 
HARVARD ALUMNI ASSOCIATION 

Harold J. Bursztajn '76 
Joseph K. Kurd. Jr. '64 

The Harvard Medical Alumni Bulletin is 

pubhshed quarterly at 25 Shattuck Street, 

Boston, \[A 02115 '' by the Harvard 

Medical .Alumni Association. 

Phone: (617) 384 8900 • Fa.x: (617) 384 8901 

Email; bullerin@hms.harvard.edu 

Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191 7757 • Printed in the U.S.A. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



SECOND OPINIONS FROM OUR READERS 



T.ETTERS 



Unsolved Mysteries 

I want to thank and congratulate you on 
the consistently superb quality of the 
Bulletin. Every issue is compulsively 
readable, and the articles are fascinat 
ing, well \\'ritten, \-aried, and informa- 
tive. In particular, the Spring 2005 issue 
on history's medical mysteries I had to 
wrest away from my wife, Morelle, a for 
mer diplomat quite innocent of medical 
arcana. She couldn't put it down. We are 
both art buffs and found Margaret Liv 
ingstone's piece on stereoblindness 
provocative and convincing. 

May I suggest that you consider fre 
quently including one or more articles 
along these lines? What, for example, 
killed Tchaikovsky — .suicide by poison 
ing, or cholera, accidentally or deliberate 
ly acquired? And what about Chopin — 
tuberculosis or cystic fibrosis? 

Another topic that might be of wide 
interest is the possible link between artis- 
tic creativity — or creati\'ity in general — 
and homosexuahty. Could this be a mat 
ter of brain structure, such as a larger 
corpus callosum in gay men? It's a fasci- 
nating puzzle. 

An additional topic that intrigues me 
is the color theory of Edwin Land — 
first proposed by Goethe. I've done 
Land's retinex theory experiment se\' 
eral times, and although logic says it 
shouldn't work, it does, amazingly. 
When I take separate black and white 
pictures of a colored object using a red 
or green filter, reverse the negatives to 
positives, project them through the 
respective colored filter onto a screen, 
and superimpose them, they do pro- 
duce a full- colored image. If you're 
unfamiliar with this, Google is a prodi 
gious resource. 

NORMAN D. LEVINE '56 
LOS ANGELES. CALIFORNIA 



The Brothers Grim 

One section of "Bewitched, Bothered, 
and Bewildered" in the Spring 2005 
issue of the Bulletin offers an interesting 



Bewitched, Rothered &r Bewllderec 



HARVARD PHYSICIANS DELVE INTO THE PAST TO DIAGNOSE A RANGE OF MYSTERIOUS MALADIES 




perspective on reasons for the so-called 
Salem delusion of 1692, but omits a like- 
ly explanation. 

In 1630, the John Winthrop fleet sailed 
from England carrying several hundred 
passengers fleeing reUgious persecution. 
Among these emigrants were three 
brothers from Bures who carried the gene 
for Huntington's chorea. Approximately 
a thousand of their descendants — some 
of whom settled in Salem and the Boston 
Bay area during the seventeenth centu- 
ry — manifested the disorder. There has 
been speculation that the Salem witches 
were choreics; indeed, Mercy Disbor- 
ough, a granddaughter of one of the Bures 
brothers, was twice tried (and pardoned) 
during the trials. Given its climcal course 
it is unlikely that all the witches, or any 
of their accusers, were afflicted with 
Huntington's disease. Nevertheless, the 
striking similarity between descriptions 
of the illness and the young girls' behav- 
iors suggests some association. 

I believe the adolescent girls were 
impressionable souls who consciously 
or unconsciously mimicked symptoms 
of choreics they observed in and around 
Salem. Although the motivation for their 
fits is uncertain, it can be understood as 
an attempt to master feelings stirred by 



observing the bizarre behaviors of those 
with the disease, an identification with 
the aggressor in the paradigm of ego psy- 
chology. Why these events culminated 
in accusations of Satan's presence is also 
unclear, though many have suggested 
Tituba's influence, and witchcraft was 
frequently in\'oked as an explanation for 
hardships endured by the villagers and 
"as much to be anticipated as Indian 
raids," according to Perry Miller's The 
New England Mind: From Colony to Province 
(Harvard University Press, 1953). This 
explanation for the Salem delusion sug- 
gests it was a psychosocial response to a 
physical illness, one that conveyed broad 
utility; the accusers reaped psychological 
benefit while \'illagers were comforted 
by the belief that they were promoting 
their secular and eternal salvation by 
rooting out Satan's messengers. 

In fairness, ergot poisoning could also 
have been the trigger for the accusers' 
actions, though I find the similarity 
between descriptions of Huntington's 
synnptoms in neurology texts and the 
girls' fits too compelling to ignore. I am 
unaware of the particulars of the other 
witch trials noted (1638-1699), but the 
fact that two of the brothers from Bures 
traveled in New England for se\'eral years 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



.^ T.KTTERS 



SECOND OPINIONS FROM OUR READERS 



before settling in Stamford, Connecticut, 
might implicate Huntington's disease in 
those events. 

STEPHEN A. GREEN, MD 
CHEVY CHASE, MARYLAND 



Best in Class 

The article by Michael LaCombe '68 on 
"Taking a History" in the Winter 2005 
issue of the Bulletin has been gnawing at 
me. Not that I can dredge up any famous 
medical "ancestors," but the article made 
me ponder the HMS faculty members 
with the greatest influence on my later 
career, which focused on designing com 
munity support systems aimed at pre\'ent 
ing a range of problems in young children. 

Two indi\'iduals came to mind; Erich 
Lindemann in psychiatry with his com- 
munity approach to preventing psychi- 
atric problems and David Rutstein '34 in 
preventive medicine who had us read the 
Newcastle- Upon-Tyne studies done in 
England. Their teaching ga\'e me my first 
real insight into the importance of under- 
standing the family and community con- 
texts that influence the distribution of 
illnesses in any population. I regret that I 
never ga\'e these faculty members tfiis 
kind of feedback while they were still 
actively teaching. I encourage others to 
be timelier in acknowledging those who 
have influenced their careers. 

Thanks for so many stimulating arti- 
cles in the Bulletin. 

R. W. CHAMBERLIN '56 
CONCORD, NEW HAMPSHIRE 



Every Step of the Way 

The anecdote that Michael LaCombe '68 
told about Paul Dudley White '11 in the 
Winter 2005 issue reminded me of my 
own experiences with Dr. White. 

One of my patients, while playing golf 
on a hot summer day in 1963, suffered a 
severe myocardial infarction. He was put 
on anticoagulant therapy and enclosed 
in a celluloid-windowed opaque oxygen 
tent, the usual treatment at the time. 

Having read in the paper that 
Dr. White was coming to our area to 




TICKET TO RIDE: Samuel Potsubay (far left) stands with Paul Dudley White (wearing the 
hat) and the mayor of Holyoke, Massachusetts, at a 1 963 dedication of a bicycle path. 



dedicate a bicycle pathway, the patient's 
wife asked about having him as a consul- 
tant in her husband's case. Dr. White 
was, at the time, the world's preeminent 
cardiologist. Luckily, I had once been a 
student of his, and he and I had several 
mutual patients about whose care we 
often communicated. So I didn't hesitate 
to telephone Dr. White's home. He agreed 
to my request, and while I drove him to 
the bicycle pathway, he told me the fol- 
lowing story: He had been imited to the 
White House by Dr. Janet Travell to see 
President John Kennedy. But when his 
plane landed, he learned that he had 
missed the bus to the Capitol and there 
wouldn't be another one for se\'eral hours. 

"How far is it to the White House?" 
Dr. White asked a clerk. "Oh, it's about 
three or four miles from here," the man 
replied, ""^'ou can just see it on the high 
ground over there." 

With that. Dr. White picked up his 
briefcase and began trudging along the 



highway Taking pit)' on the elderly man 
plodding along, passing motorists offered 
him rides, which he poUtely declined, say- 
ing he needed the exercise. When he final- 
ly arri\ed at the White House drenched 
in sweat, he told the incredulous guard 
that he had been summoned by Dr. Travell. 
When she arrixed and learned of his trek, 
she said, "Just a second. Lll go get Jack." 
When President Kennedy appeared, he 
exclaimed, "Gracious me. Dr. White! I'm 
told you walked all the way from the air- 
port. You must be exhausted!" Dr. White's 
gruff reply was, "Oh, it wasn't so bad. But 
you sure have lousy sidewalks down here!" 

SAMUEL POTSUBAY '4O 

SOUTH HADLEY, MASSACHUSETTS 

The Bulletin welcomes letters to the editor. 
Please send letters by mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115): fax (6l7'384'890l): or 
email (bullctin(^hms.han'ard.edu). Letters may 
he edited for length or clarity. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



r^ 






MAKING THE ROUNDS AT HMS 



PTIT.SEy 



Salad Days 



D 



O RUN A LITTLE FASTER AND JUMP 

a little higher, HMS faculty 
appear to rely more on good 
health habits than on Air 
Jordans. At least that's what might be 
derived from the responses of 2,115 facul 
ty members who were surveyed recently 
by the Hanard Health Letter. The survey, 
developed to mark the periodical's 30th 
anniversary, reprises similar 
polls by the publication 
conducted in 1982 and 1992. 

The sur\-ey's results show- 
that most respondents 
adhere to the same healthy 
diet and exercise regimens 
they likely suggest to their 
patients. For example, near 
ly half exercise at least three 
times a week at an intensity 
gauged to be moderate or 
higher. Their preferred forms 
of exercise? Walking (35 
percent) or jogging (24 per- 
cent) with about 13 percent 
choosing to cycle. 

Eighty-two percent eat 
breakfast regularly and a 
little less than half consume 
three to four servings of 
fruit or vegetables each day. 
Crunchy granola and its 
whole-grain cousins, how 
ever, are popular only with 
about 33 percent who eat 
three or more servings of 
whole grains each day. 

About 12 percent fessed 
up to eating at fast food 
places weekly; about half drink alcohol in 
moderation, imbibing between one and 
five drinks per week; and nearly 57 per 
cent use oh\'e oil rather than other t)'pes of 
fats when preparing food. And for shghtly 
more than half the respondents, it's not the 
chee-se that stands alone, it's the egg, which 
appears less than once a week on menus. 

Although 46 percent eat fish at least 
twice a week, only 9 percent swallow a 



capsule of fish oil regularly. Other vita 
mins and supplements taken regularly 
include multi\'itamins (nearly 78 percent) 
and vitamin E (13 percent). Nearly 18 per- 
cent take vitamin C, but the urge to up 
that intake when battling a cold is low, 
with almost 74 percent shunning that 
remedy. For more than one quarter of 
the respondents, standing straight and 




strong is likely helped along by calcium 
supplements. Herbal supplements rank 
low among respondents; 72 percent had 
never taken St. John's wort, ginkgo, gin- 
seng, or similar substances. 

A greater percentage than might be 
found among the general population know 
their body mass index (48 percent) and 
the prevailing definitions of "overweight" 
and "obesity" based on that index (nearly 



69 percent). To help keep their body mass 
in check, nearly 48 percent had dieted 
in the past five years. But to reach their 
weight goals, most avoided the trendy 
low fat and low carb diets, opting to fight 
the good fight by controlling food por- 
tions (55 percent). Only about 20 percent, 
interested in doing a little adding while 
subtracting, chose to count calories. 

Fifty se\'en percent rated 
their risk of heart disease as 
low. When asked what they 
do to reduce their risk, or 
to keep it low, exercise 
walked away with the 
prize, with nearly 74 per- 
cent opting to pump up 
their heart rate on a regular 
basis. Cutting down on the 
consumption of saturated 
fats was a solid second at 
nearly 62 percent. Some- 
what surprisingly, nearly 12 
percent did nothing, appar- 
ently depending upon good 
fortune — or good genes. 
Around 44 percent know 
neither their low-density 
lipoprotein nor high- densi- 
ty lipoprotein levels, and 
more than three-quarters of 
the respondents eschew use 
of low dose aspirin. 

Of the 98 percent who 
don't smoke now, about 76 
percent indicate they have 
never smoked. 

Doctors do turn to other 
doctors for medical needs, 
according to the survey. Sixty-one percent 
had received a physical within the past 
year and 92 percent have a primary care 
physician. So that personal health deci- 
sions may be taken care of down the road, 
more than 35 percent have both a health 
care proxy statement and a Uving will. 

The full results of the survey were 
published in the October issue of the 
Harvard Health Letter m 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



ptit.se 



MAKING THE ROUNDS AT HMS 




The Class 
of 2009 



The Art Is Long 




THE CENTER FOR THE HISTORY OE MEDICINE AT COUNTWAY LIBRARY HAS 

taken on another role recently — as a patron of the arts. Ars Longa — 
Vita Brcvis, an exhibit of digital collages developed for the 
library by artist Dorothy Simpson Krause and debuted in Count- 
way's first floor exhibit area, has found a permanent space online at 
www.dotkrause.com/art/ArsLonga/index.htm. Krause, a printmaker who uses 
digital images to create multilayered works, is the library's first artist-in-resi- 
dence. A professor emeritus at the Massachusetts College of Art, she is regard- 
ed as a pioneer in digital printmaking. 

To produce the works in the exhibit, Krause sifted through the collection of 
about 13,000 objects in the center's Warren Anatomical Museum before pho- 
tographing a number she considered to have visual power and to represent 
"timeless personal and universal issues." 

In the work Insurance, shown above, Krause printed photographs of \'arious 
views of a skull onto clear film, mounted the transparent images over small 
mirrors, then framed them with pages from a handwritten journal of life insur- 
ance payments found at a flea market. 

By juxtaposing photographs of the objects selected from the collection with 
more ordinary items, including ephemera she has collected, Krause sought to 
produce works that would "humanize" the objects and pro\'ide them a more 
accessible context. ■ 



THE 165 NEWEST MEMBERS OF THE 

Harvard Medical School communi- 
ty, the Class of 2009, donned 
bright emblems of their new careers 
during the School's White Coat 
Ceremony in September. Women 
form the majority at nearly 52 per- 
cent of the class. The class includes 
graduates from 62 different under- 
graduate institutions in 32 states, 
the District of Columbia, and Puer- 
to Rico, as well as from Australia, 
Canada, France, Germany, Hong 
Kong, Pakistan, and Sri Lanka. 
Thirty-three percent of the students 
are Asian Americans, 12 percent 
ore African Americans, 9 percent 
are Latinos, and 1 percent are 
Native Americans. 

The ages of students in the 
class range from 19 to 37. As 
undergraduates, 72 percent of the 
class majored in the sciences, 1 1 
percent majored in the social sci- 
ences, 6 percent majored in the 
humanities, and 1 1 percent 
majored in other disciplines or 
were double majors. ■ 




CLOTHES MAKETH THE MAN: Takahira 
Soda '09 >vrestles with his new garb 
during the White Coat Ceremony 
of the Division of Heolth Sciences 
end Technology. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



PRESTDK NT^S REPORT 




Lasting Impressions 




ARim'ED AT VANDERBILT HALL LATE ONE RAIl^Ti' NIGHT 

in the fall of 1960, in the wake of Hurricane 
Donna. I was a scared California boy, kno\\ing no 
one in my class and worried that I was in way over 
my head academically. The trunk that had been sent with 
my blankets and clothes was locked away, and I faced the 
prospect of a cold night in a strange place. Fortunately, a 
fourth-year student in the room next to mine looked in, 
diagnosed my plight, and loaned me bedding. The next 
morning I met my classmates, and the adventure began. 

Now, 45 years later, I can appreciate how much Harvard 
Medical School changed my life. For one, it made me a 
disciphned student — especially after I flunked my first 
biochemistry class. More important, exposure to genuinely 
intellectual classmates gave me a vision of what hard work 
and dedication could accomplish. It is now my privilege to 
serve the School as president of its Alumni Council. HMS 



of Health would dwarf the total for the next most competi- 
tive academic medical center. 

Finally, it is much more diverse. My Class of 1964 had only one 
person of color and five women out of 150 students. By con- 
trast, 52 percent of the Class of 2009 are women and 22 per- 
cent are underrepresented minorities. Unfortunately, progress 
in achieving di\'ersit)' at the residency and faculty levels, though 
a priority, has been slower. In addition to a growing diversity of 
people, the School features an increasing diversity of activities as 
it keeps up with the forces propeUing clinical care and research. 

Does this mean that HMS has no problems? Of course not. 
Most of its challenges are shared by all elite U.S. medical 
schools in the twenty- first century, though I suspect that 
Harvard's competitors would cheerfully undertake a trade. 
The \'ery success of recent research efforts makes it difficult to 
sustain momentum at a time when fundmg has plateaued, 
and a strength of HMS — its many separate scientific enti- 




Harvard's clinical institutions must cope with the national 
problems of a huge number of uninsured people and 
> escalating pressures to reduce medical costs. 



has more than 9,000 li\ing alumni, probably about 75 per- 
cent of whom h\'e outside the Boston area in a kind of med- 
ical diaspora. For those of you who have not visited HMS 
recently, let me share some impressions from my recent trips. 

First of all, it is hi^a: A second quadrangle has sprung up on 
Avenue Louis Pasteur, anchored by the New Research Build- 
ing, v\ith nearly half a million square feet devoted to basic 
research. The Harvard affiliated hospitals are behemoths, 
whether judged by their physical plants, revenues, research 
budgets, or patient numbers. Not surprisingly, the number of 
HMS faculty also has growTi, with more than 9,000 salaried 
members either on campus or at the hospitals. More than 
7,200 interns, residents, clinical fellows, and postdoctoral 
fellows train at the 18 affiliated institutions. 

HMS is more than big: it is also talented. It attracts top students, 
residents, fellows, and facult)' The combination of size, 
brainpower, resources, and energy creates a dazzling array of 
intellectual talent in \irtually all aspects of medicine. HMS 
regularly appears as the best medical school in the various 
ratings of academic institutions, and its hospitals rank in the 
upper echelon of such lists. The sum of all grants that Har- 
vard- affihated faculty have won from the National Institutes 



ties — also inhibits collaboration. In terms of education, the 
accelerated pace of patient care has left many clinician-edu- 
cators struggling to provide students in the clinical years 
with the necessary teaching time and effort. In addition, the 
mounting costs of medical education and Uving expenses leave 
far too many graduates mired in huge debt. Finally, Harvard's 
clinical institutions, though extremely well positioned in 
the Boston market, must still cope with the national prob- 
lems of a huge number of uninsured people and escalating 
pressures to reduce medical costs. 

These are one person's general impressions of Harvard 
Medical School today. It is and will remain a great institu- 
tion. I encourage you to visit the campus — at reunion time 
or during the year — to form your own impressions. And, 
if you have ideas you would like to communicate to your 
Alumni Council, please feel free to contact me at 
schroeder@medicine.ucsf.edu. ■ 

Steven A. Schroeder '64 is a distinguished professor of health and 
health care in the Department of Medicine at the University of Cali- 
fornia at San Francisco, where he also directs the Smoking Cessation 
Leadership Center 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 




ROOKMARK 



I REVIEWING THE PRINTED WORD 



The Health Care 
of Homeless Persons 

A Manual of Communicable Diseases & Common Problems in Shelters 
&on the Streets, edited by James J. O'Connell '82 with Stacy E. 
Swain, Christine Loeber Daniels, andjoslyn Strupp Allen 
(Boston Health Care for the Homeless Program, 2004) 



THE PHOTOGRAPHS IN THIS IMPASSIONED AND STURDY BOOK ARE 

a tour of humanity. Some are hard to look at — a generic foot 
with yellow nails being eaten away by maggots; the "linear 
burrows" of scabies up and down an anonymous arm; a 
pile of garbage with someone sleep- 
ing alongside it; a man soaking his 
bloodied, bandaged feet, yet grin- 
ning with pleasure that someone is 
taking his picture. Some are beauti- 
ful in purpose, like the shelter work- 
er suited up in a garbage bag, clutch- 
ing a bottle of lice shampoo, glaring 
at the camera and ready for work. A 
man bedded down under the beams 
of a bridge gazes at the nurse hand- 
ing him medication by flashlight. 
Staff and patients in a respite facili- 
ty lean together. A fellow with dap- 
per knees sits near a fire hydrant, 
and the caption reads: "Outreach 
nurse and case worker bring daily 
TB medications to this elderly poet." 
In the loving nouns and adjectives, 
side by side with immunization 
charts and HIV drug lists, there is 
awe for the patients themselves. 

The awe is one of the results of a 
long collaborative medical effort. In 
1985, the Boston Health Care for the Homeless Program was 
launched with a grant and eight staff members. Now the staff 
numbers 250, with a base of three hospitals and 70 outreach 
sites. (I serve part time as a psychiatrist with the program.) 
All together, more than 8,000 patients recei\'ed treatment 
last year. Extant office branches can be found under bridges 
and behind dumpsters. Business is brisk. 

For a population without homes, life is a series of practi- 
cal, threatening constraints: no place to refrigerate insulin, 
elevate a cellulitic foot, or check a fever every four hours; 
endemic oral infections; hypothermia and hyperthermia at 
the whim of the season; sleeping bodies feeding bedbugs; 
and close quarters spreading infections. "The clear lesson of 
two decades of caring for homeless persons is straightfor- 




ward," writes James J. O'Connell '82, president of the Boston 
Health Care for the Homeless Program and editor of The 
Health Care of Homeless Persons, "housing is health care." With- 
out housing, treatment is symptomatic. 

Chapters are practical, since there is no time to waste. 
Impetigo, hepatitis A, and tuberculosis spread quickly in 
shelters; hce carry Bartonella, certain species of which cause 
trench fever and endocarditis; and the "rough sleepers" U\Tng 
outside have it worse. "Assume that no one is dead until 
[they are] 'warm and dead,'" ad\'ises a terse paragraph on 
hypothermia treatment. "Resuscitation efforts should con- 
tinue until the body temperature reaches 90-95 F." Street 
diagnosis is complicated by the fact that most thermometers 
don't register accurately below 93T. A wind-chill chart plot- 
ting degrees Fahrenheit versus min- 
utes to frostbite is included. 

Each chapter carries standard sec- 
tions on the transmission, diagnosis, 
and treatment of communicable and 
chronic diseases. Many chapters, 
whether on nosocomial infections, 
food management, sexually transmit- 
ted diseases, or traumatic brain injur); 
.ilso have a section, "Special Consider- 
ations for Homeless Populations." It 
seems redundant at first — isn't the 
entire book about homeless popula- 
tions? But these sections are more spe- 
cific. When evaluating hyperthermia, 
for instance, consider the gentle possi- 
bility that paranoid patients, who 
wear layers of winter clothing all sum- 
mer, "may be amenable to a creative 
discussion about dressing more Hght- 
ly." When treating sinusitis, remem- 
ber that, "humidification with steam 
[is] impractical for most shelter resi- 
dents or people who sleep on the 
street." Pharmacology for the uninsured (and sometimes 
unnamed) also comes with constraints. Lists of medications 
at the end of each chapter ha\'e dollar signs beside them. 
Browsing through them is useful, though a little ironic, like 
reading a travel book for best buys on hotels. 

We are a nation consumed, on the one hand, with best 
buys, and on the other, with the assailable comiction that 
costher is better. A recently pubhshed 17th edition of the 
Sabiston Textbook of Surgery will run you $159. Youmans 'Neuro- 
logical Surgery (5th edition) runs $839. The Health Care of Home- 
less Persons manual is $15. Read here to learn about homeless- 
ness and health care, but also about humanity. ■ 

E/is.si:J Ely 'SS is a psychiatrist at the Massachusetts Mental Health Caita: 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



BOOKS BY OUR ALUMNI 



ROOKSHET.F . 



Ready ok 

, NOT. 
HERE 




;^ J/ 

REASTtM^CER 

Vladimir Lance m.d. 




Ready or Not, Here Life Comes 

by Mel Le\ine '66 [Simon c~ Schuster. 2005) 



Le\'ine examines why so many twenty 
somethings or "startup adults" seem to 
flounder during post-college years and 
be unprepared for working life. He urges 
high schools, teachers, and parents to 
give adolescents the tools they need to 
navigate life and work, such as sell 
awareness, an understanding of unwrit 
ten expectations, and social skills. 

Sugar & Spice and No Longer Nice 

How \Vc Can Stop Girh' \ tokncc. 

by Deborah Prothrow Stith 79 and 

Howard R. Spi\ak (josscy Bass, 2005) 



The authors describe and analyze the 
alarming trend of increasing violence 
perpetrated by girls. During the 1990s, 
they write, arrests of girls for aggravat- 
ed assault increased by 57 percent, and 
by 2003, one in three juveniles arrested 
for violent crimes was a girl. They offer 
explanations, including the influence of 
violent images and \ioIent female super 
heroes in entertainment media, and give 
tips for parents, teachers, and communi 
ties to stop the trend. 

And Tango Makes Three 

byju.stm Richardson "89 and 

Peter Parnell; illustrated by Henry Cole 

(Simon & Schuster, 2005) 

This charmingly illustrated children's 
book teUs the true tale of Roy and Silo, 
two male chinstrap penguins at New 



York City's Central Park Zoo who seemed 
to want a family of their own after watch- 
ing how other penguin couples made 
nests and cuddled with their baby chicks. 
A sympathetic zookeeper filled the cou- 
ple's \'acant nest with an extra egg, which 
later hatched to reveal Tango. 

Unfinished Work 

Building Ec^iuditv and Democracy in an Era of 
Wbrkmg Families, byjody Heymann '88 
and Christopher Beem (New Press, 2005) 



This book asserts that parenting is essen 
tial, socially productive labor, which 
needs more respect and federal support 
through policy and tax benefits. The 
authors examine historical workplace 
and chUdcare trends and how they ha\'e 
influenced today's gaps in equality at 
home and at \\'ork. They offer solutions 
that would assist working families at all 
income le\'els, including paid family lea\'e 
and flexible work schedules. 

Be a Survivor 

Your Guide to Breast Cancer Treatment, 

by Madimir Lange '72 

(Langc Productions, Third Edition, 2005) 



Lange's book helps women navigate 
the different breast cancer treatment 
choices available. Survivors' candid 
personal stories accompany practical 
checklists of questions for doctors and 
insurance companies. Illustrations pre- 
pare women for what to expect during 
the treatment process, and a DVD, new 
for the third edition, provides film clips 
of actual procedures. 



Private Practice 

In the Earh Twentieth Century 
Medical Office ofDr Richard Cabot, 
by Christopher Crenner '92 
Qohns Hopkins University Press, 2005) 

Crenner probes a critical period in 
medical history through the lens of the 
practice of Boston physician Richard 
Cabot, Class of 1892, an HMS professor 
and director of the medical service at 
Massachusetts General Hospital. The 
book includes Cabot's correspondence 
with his patients during the early years 
of the twentieth century, when the rise 
of ad\anced medical technologies fre- 
quently baffled patients and physi- 
cians alike. The author provides 
insight into the way those new tech- 
nologies transformed the traditional 
doctor-patient relationship. 

Social Injustice and Public Health 

Edited by Barry S. Levy and Victor W. 
Sidel '57 (Oxford University Press, 2006) 

Levy and Sidel focus on how social 
injustices — such as poverty, racism, and 
ageism — compromise the health of vul- 
nerable populations. The authors sug- 
gest multiple solutions to bridge 
"unconscionable" gaps, including con- 
structing international and national 
human rights policies, developing more 
public health education, and providing 
disadvantaged indi\'iduals with social 
networks within communities. Address- 
ing social inequaUty, the authors wTite, 
wall help all Americans realize the core 
values of freedom. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



RENCHMARKS 



DISCOVERY AT HMS 




A Pitch for What Ails You 



IVING A WHOLE NEW MEANING 

to sports medicine, HMS 
researchers at Children's 
Hospital Boston have found 
that during key Red Sox games — specif- 
ically the race-for-the pennant ones in 
2004 — visits to six Boston area emer- 
gency departments dropped. 

And the more riding on the game, the 
bigger the drop. The inxestigators found 
a dip of only 5 percent in expected vol- 
ume during game 5 of the American 
League Championship Series (ALCS) — 
when a Sox loss would ha\'e put them 
out of the race — but found a 15 percent 
or greater drop in expected traffic during 
ALCS games 6 and 7 and the reverse-the 
curse game 4 of that year's World Series. 

The authors of the study — Kenneth 
Mandl '89, senior author and an HMS 
assistant professor of pediatrics, as well 
as HMS pediatrics instructors John 
Brownstein and Ben Reis — are all Red 
Sox fans. For Mandl and Reis, who 
grew up in Boston, their allegiance to 
the Sox is natural. For coauthor 
Brownstein, who moved to Boston 
from Montreal, becoming a Sox fan 
was an acquired taste, one that formed 
after he became infected with what he 
calls "game fever." 

In their bid to measure health-care 
use during pivotal sporting events, the 
Childreris team did what baseball fans 
do best — they compiled the stats. Bor- 
rowing data from AEGIS, a disease-sur- 
veillance system used at Childrens to 
analyze patient data and flag abnormal 
outbreaks and patterns of disease, the 
researchers tracked hourly \'isit rates to 
six area emergency departments — Chil- 
dren's, Beth Israel Deaconess Medical 
Center, Massachusetts General Hospi- 
tal, Cambridge Hospital, Somerville 
Hospital, and Whidden Memorial Hos- 
pital — during each of the 2004 ALCS 
and World Series games. They then 
plotted the emergency- department \'isit 
rates against television viewership rates 
generated through local Nielsen ratings. 



10 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




FEVER PITCH: Pedro Martinez v^orks the mound for the Red Sox in the third gome 
of the 2004 World Series. 



Long hours of number crunching 
yielded a statistically sound inverse rela- 
tionship between Red Sox viewership 
and emergency-department visits, 
telling the researchers that the bigger or 
more suspenseful the event, the quieter 
the emergency department. 

During the lowest rated games — 
ACLS games 3 and 4 when the Sox were 
losing and could have been knocked out 
of the championship run — visits to the 
emergency room were about 15 percent 
higher than normal volume, even when 
the researchers adjusted the numbers to 
account for time of day, day of week, 
and seasonal factors that can .spike visit 
rates, such as a flu outbreak. But after 
game 4, when the Sox were again con- 
tenders for a spot in the World Series, 
Nielsen ratings surged and emergency 
department visits slumped — about 
5 percent below normal volume. By 
game 7 of the league championship 
series and game 4 of the World Series, 
between 55 and 60 percent of Boston 
households had televisions tuned to the 
games and emergency departments 



were hushed, operating at le\'els 15 to 
22 percent below normal volume. 

This study contrasts with a pre\ious 
stud)' by other researchers who found a 
spike in dri\'ing fatahties on football's 
Super Bowl Sunday, a situation that 
would likely increase the number of 
emergency- department \isits. The HMS 
research team, however, looked at emer- 
gency-department \isits only during the 
hours of the games themselves and not 
during the periods of celebration that 
followed the e\'ents. They examined all 
categories of visits, including routine 
health visits. 

Do sports have a prophylactic effect? 
Probably not, say the researchers. 
Major televised sporting events likely 
just lead to more home-based triage — 
if it's not a heart attack or doesn't 
im'olve profuse bleeding, people sim- 
ply exercise greater discretion when 
deciding whether to head for the 
emergency department. 

The researchers' findings appear in 
the October issue of the Annals oj Emer- 
gency Mcdkinc. m 



THE CENTER CANNOT HOLD 



P MAGES BLUR, STRAIGHT LINES CROOK, AND 
then the middle goes missing. This cascade of 
chonges to a person's field of vision catalog the 
symptoms of neovascular macular degeneration, 
an age-related eye disease that can lead to blindness in a 
large number of the individuals it afflicts. 

Knowledge useful to the prevention and treatment of 
neovascular macular degeneration has proven elusive. 
Researchers at the Massachusetts Eye and Ear Infirmary 
and HMS, however, may have found o clue: the bacterium 
Chlamydia pneumoniae. Their recent study found 
the organism in diseased eye tissue from five of nine 
individuals with neovascular macular degeneration. The 
researchers brought the significance of this finding into 
greater focus when they discovered that eye tissue from 
20 individuals without age-related macular degeneration 
showed no sign of the organism. The results appear in 
the November issue of Craefe's Archive for Clinical and 
Experimental Ophthalmology. 

Age-related macular degeneration (AMD) has two 
forms, nonneovascular ("dry") and neovascular ("wet"). 
Each results from damage to the eye's macula, a small, 
centrally located part of the retina, the light-sensitive layer 
of tissue that lines the back of the eye and transmits nerve 
impulses to the brain. Tallies of the incidence of both forms 
show the disease currently affects between 3.5 million and 
10 million people in the United States over the age of 65. 

In the dry form of the disease, the layer of cells under 
the retina stops functioning well, causing the light-sensing 
cells of the overlying retina to malfunction or even disap- 



pear. In time, this damage to the retina produces blank 
spots in the central portion of the eye's visual field. Some 
degree of vision loss occurs in 90 percent of such cases. 

Wet macular degeneration is less common but consider- 
ably more serious. In this form, the macula becomes 
scarred by blood and fluid leaking from delicate new 
blood vessels that sprout beneath the retina. Damage and 
scarring occur quickly. Vision diminishes in a matter of 
days or weeks and continues to degrade over time. This 
form of the disease frequently leads to vision loss so signifi- 
cant that it qualifies as legal blindness. 

The new study shows that infection by C. pneumoniae 
modifies cells that regulate normal eye function by increas- 
ing their production of vascular endothelial growth factor 
(VEGF), a protein involved in wet AMD. 

"The fact that human eye cells infected with this bacteri- 
um increase VEGF production," says lead author Murat 
Kaloyoglu, an HMS research fellow in ophthalmology at 
the Massachusetts Eye and Ear Infirmary, "could explain 
in part why VEGF levels are higher in many people with 
wet AMD." 

This research, which builds on the scientists' earlier 
investigations linking AMD with an infectious agent, adds 
to a growing list of studies that have looked into the role of 
inflammatory mediators in AMD. 

Although using antibiotics to control C. pneumoniae 
infection may ultimately be key to controlling this disease, 
Kaloyoglu says more research is needed before individuals 
with neovascular macular degeneration can look to antibi- 
otic therapy to fill the voids in their vision. ■ 




CLOAKED IN OBSCURITY: Age-related degeneration of the macular region of the retina, which is caused by blood leaking 
from ne>vly formed vessels, is characterized by the loss of central vision that, in some cases, con become significant 
enough to qualify as legal blindness. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



RFNC HMARKS 



DISCOVERY AT HMS 




Every Breath You Take 



HE TINY BUBBLES SEEM TO SIGH 

as they release their con- 
tents. Rehef? Maybe. After 
all, they have held their air 
tightly for millennia. Or perhaps it's 
sadness, knowing they bear bad news. 

Air that has been encased in Antarc- 
tic ice tells scientists that today's atmos- 
phere has levels of climate-changing 
gases that are vastly higher than those 
bathing Earth during the past 400,000 
to 650,000 years. Carbon dioxide alone 
is measured at concentrations more 
than 30 percent higher today than any 
Earth has seen in the past four hundred 
thousand years. 

That's enough to make us sick, say 
researchers who produced Climate Change 
Futures: Health, Ecological, and Economic 
Dimensions, a report from the Climate 



Change Futures Project at the Center 
for Health and the Global Environment 
at HMS. Paul Epstein, associate director 
of the center and an HMS instructor in 
medicine, led the group that produced 
the report. The three-year study was 
cosponsored by the center, the United 
Nations Development Programme, and 
Swiss Re, a global reinsurance compa- 
ny in Zurich. 

The report finds that the climate 
change associated with rising levels of 
the gases that are produced when fossil 
fuels combust seriously undermines 
human health, alters ecosystems, and 
takes a big chunk out of the global wallet. 

Climate-changing gases like carbon 
dioxide trap heat in the atmosphere. 
Over time, as rising levels of gases hold 
more heat, the climate refashions. Its 



alterations can manifest themselves 
subtly, as incremental increases in 
temperature that take place over years, 
or they can show themselves in dra- 
matic fashion, as with extreme weath- 
er events such as intense hurricanes 
and heat wa\'es. Overall, according to 
the report, climate change promotes 
the production of plant pollen, soil 
bacteria, and fungi; alters the composi- 
tion of species by favoring opportunis- 
tic weeds such as poison ivy and rag- 
weed; and spurs the growth of popula- 
tions of organisms responsible for 
infectious diseases. Such environmen- 
tal insults are all the more significant 
because they harm our health. 

The incidence and severity of respira- 
tory ailments, for example, are exacer 
bated by photochemical smog, also 




12 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



knowTi as ground-level orone, which 
is formed by car emissions, diesel par 
ticulates that deliver pollen and molds 
deep into the lungs, and the soup of air 
pollutants and aeroallergens carried 
on masses of unhealthy air. 

Children are particularly vulnera- 
ble, says the report, especially those 
living in poor communities in the 
inner cities. Epstein speculates that 
higher concentrations of ragweed 
pollen as well as pollen from other 
plants may have spawned the rise in 
asthma rates being registered in the 
United States — a fourfold increase in 
cities in recent years alone — and 
throughout the world. Treating asth- 
ma in those under the age of 18 costs 
the United States an estimated $3.2 
billion per year. 

Another area of concern the report 
raises is the growth in infectious dis- 
eases. In the past three decades, as 
many as 30 infectious diseases have 
emerged. The ten case studies in the 
report outline how climate change 
also contributes to the increased 
prevalence of diseases such as malaria. 
West Nile virus, and Lyme disease. 

Lyme disease, for example, is on the 
rise in North America because increas- 
ingly milder winters cannot effectively 
check the proliferation of the ticks 
that carry the disease from animals to 
humans. The report says a twofold 
increase in welcoming habitats for 
these ticks is expected by the 2080s. 
Warmer and wetter weather also pro- 
motes the breeding and range of mos- 
quitoes that carry malaria and animals 
that transmit the West Nile virus. 

To stem the health and environmen- 
tal damage caused by increases in car- 
bon dioxide and other fossil- fuel com- 
bustion products, the report's authors 
recommend curtailing the use of such 
fuels by replacing them with clean 
energy alternatives, "green" buildings, 
and transportation modes that exploit 
hybrid technologies. ■ 



WOMEN'S HEALTH 




n*^ NEW TAKE ON TAKING TWO 

Every dose of acetaminophen or ibuprofen a 
woman swallows increases her risk of devel- 
oping high blood pressure, says a study in 
the September issue of Hypertension by a 
Brigham and Women's Hospital team led by 
John Forman, HMS instructor in medicine. 
The four-year look at painkiller use among 
5, 1 23 women in the Nurses' Health Studies 
found that for a group of women between the ages of 51 and 77, taking 
more than 500 milligrams daily (the equivalent of one extra-strength aceta- 
minophen tablet) increased hypertension risk 93 percent; for a group of women 
between 34 and 53, the risk increased twofold. More than 400 milligrams 
daily (about two tablets of ibuprofen) raised risk 78 percent for older women 
and 60 percent for younger women. Aspirin use did not increase risk regard- 
less of age. 

11^ GETTING THE RED OUT 

More than 8 million people in the United States, predominantly women, suffer 
from dry eye syndrome. Without the proper kind or amount of naturally pro- 
duced tears, their eyes feel gritty and damage easily. Findings in the October 
issue of the American Journal of Clinical Nutrition indicate women might look 
to their diets to prevent dry eye. Biljona Miljanovic, HMS research fellow at 
Brigham and Women's Hospital, reports that responses from 37,000 women 
in the Women's Health Study show that consuming more omega-3 fatty acids — 
found in tunc and walnuts — reduced risk for the syndrome. Omega-6 fatty 
acids — in foods such as solod oils and animal meats — increased risk. 

\\l^ TIME WELL SPENT 

Breastfeeding makes for a healthier baby, and, according to new research, a 
healthier mom, too — by lowering her risk for developing diabetes later in life. 
Research by a team led by Alison Stuebe, HMS clinical fellow at Brigham and 
Women's Hospital, shows that mothers who breastfed for at least one year 
were 1 5 percent less likely to develop Type 2 diabetes than mothers who did 
not breastfeed. And more was better — each additional year of breastfeeding 
brought a greater reduction in risk. For women with gestational diabetes, 
however, breastfeeding did not lower risk. The research, involving more than 
157,000 women in the Nurses' Health Studies, appears in the November 23 
issue of the Journal of the American Medical Association. 

m KICKIN' BACK WITH JOE 

Coffee does not increase women's risk for high blood pressure but cola beverages 
do. This finding, in the November 9 issue of the Journal of the American Medical 
Association, stems from a 1 2-year study of 1 55,000 women in the Nurses' Health 
Studies at Brigham and Women's Hospital. Women who drank regular or diet cola 
had an increased risk for hypertension — 26- to 46-year-olds who daily drank four 
or more sugared colas had a 28-percent increase in risk over women who drank 
less than one. For women between 43 and 71 , drinking four or more colas daily 
increased risk 44 percent over peers who drank less than one. For diet cola 
drinkers, consuming four or more of the beverages daily raised risk 1 9 percent for 
the younger group and 1 6 percent for the older group. The study's lead author is 
Wolfgang Winkelmayer, HMS assistant professor of medicine. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 






SPECIAL REPORT: THE UNINSURED 



Gaps in health insurance 
have created a new caste 
system in the United States. 




BY RUSHIKA FERNANDOPULLE 



Y THE TIME WE MET HER, GINA HAD ALREADY ENTERED 

I this country's social underclass, a victim of the 
nation's health- care death spiral. A plain and weary 
young woman with faded blond hair, Gina suffers 
from chronic stomach pains that have worsened 
over time. She had self-diagnosed the problem as a mixture of 
indigestion and the stress brought on by her financial situa- 
tion. She works at FabuCuts, a national chain specializing 
in low-cost haircuts for walk-in customers. In an average 
month of working nine-hour days, she takes home about 
$900, barely enough to cover her rent, utilities, car insurance, 
food, and payments for the $15,000 she borrowed to attend 
hairdressing school. Although FabuCuts offers its employees 
health insurance, Gina cannot afford the monthly premium, 
deductibles, or copayments. 




14 I HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




:-^,i^-\ 



The issue of uninsurance affects not just 

the uninsured, but everyone in the nation. 



This lack of coverage has become a crisis. 
When her stomach troubles first started, 
Gina took over-the-counter antacids, 
but when the pains became unbearable, 
she went to the local emergency room. 
There a physician diagnosed a bladder 
infection, prescribed an antibiotic, and 
told her to see her regular doctor if she 
didn't improve. When she tried to see her 
previous physician, the office required 
cash up front because she was uninsured. 
Only then \\'as she allowed to see a physi- 
cian assistant, who diagnosed a kidney 
infection and gave her more antibiotics. 
The pain continued and a few weeks 
later she returned to the emergency 
room, where she received a diagnosis of 
gallbladder problems and a $5,000 bill. 
Another visit to her doctor led to anoth- 
er trip to the hospital, a $4,000 bill, and a 
recommendation to see a surgeon. Yet 
without insurance she must pay $200 
before the surgeon's office will e^'en 
schedule a consultation. 

At this point, Gina's pain comes and 
goes; she knows stress makes it worse, 
but the condition itself causes consider- 
able stress. She and her husband — \\'ho 
earns $6.25 an hour and does not qualify 
for health insurance — want to start a 
family, but can't even consider children in 
their current situation. Gina knows her 
gallbladder could rupture if left untreat- 
ed, causing her to lose parts of her bowel, 
become infertile, or even die. She has 
learned to live with the pain, but not 
with the fear. She knows that even if she 
could scrape together the $200 for the 
surgical consultation, she could never 
afford the surgery. What frustrates her 
most is that she and her husband work 
hard and yet find themselves falling only 
further behind. 

DOES IT MATTER TO BE UNINSURED? 

Several years ago I found myself at a 
health care symposium sitting next to 
Susan Starr Sered, a medical anthropolo- 



gist at Harvard Di\'inity School. One of 
the speakers shared survey results that 
seemed to deny Gina's experience. The 
survey, sponsored by the Kaiser Family 
Foundation in 2001, found that 55 per- 
cent of all American adults agreed with 
the statement that it doesn't really mat- 
ter if you're uninsured because you can 
get all the care you need anyway at an 
emergency room or a free cHnic. 

Susan, knowing my background as a 
practicing internist who had long 
worked in the area of health care policy, 
leaned over to ask me whether this 
belief was true. I pointed out that the 
In,stitute of Medicine, a respected, non- 
partisan federal advisory board, had 
recently issued a six-volume series sum- 
marizing hundreds of peer-reviewed 
studies showing that being insured 
does indeed matter. Compared to those 
with insurance, uninsured people get 
diagnosed later, suffer more pain, 
endure more complications, experience 
worse outcomes with virtually every 
major chronic condition, and die sooner. 

The problem, Susan said, was that such 
data com'inced no one. What persuades 
the American pubhc, she added, are sto- 
ries, not data — and perhaps that's what 
the national debate is lacking. We decided 
to leverage our disparate backgrounds 
and perspecti\'es to get a better handle on 
the issue. We would tra\'el across the 
country to ask consumers, providers, and 
ad\'ocates a few simple questions: What 
does it mean to be uninsured in America 
today? What is and is not possible for 
uninsured people, and hov\' does being 
uninsured affect their lives? 

We decided to focus on fi\'e areas of 
the country \\ ith different patterns of 
uninsurance: the Mississippi Delta, 
where residents live in stark po\'erty; 
the cohnias of southern Texas, whose 
population has the highest rate of unin 
surance in the nation; rural northern 
Idaho, where the collapse of the mining 



and logging industries has left many 
uninsured; urban areas in central Illi- 
nois from which large industry is flee- 
ing; and eastern Massachusetts with its 
increasing population of the "middle- 
class uninsured." 

One year and more than a hundred 
interviews later, we had gained a much 
sharper understanding of the issue. We 
were touched by the willingness of peo- 
ple like Gina to spend hours with us, 
sharing deeply personal stories of how 
their lack of insurance has undermined 
their health and lives. We also met doc- 
tors and other providers who have 
accepted huge cuts in pay, limited 
access to resources, and scanty back-up 
to help underserved populations. The 
problem, we concluded, is structural, 
affecting not just the uninsured, but 
everyone in the nation. 

THE ROAD TO NO CARE 

We are all too familiar with the figure of 
45 million Americans who chronically 
lack health insurance. But there are many 
others who find themselves cycling 
on and off coverage depending on their 
employment, their life situations, and 
changing eligibility criteria. The Com- 
monwealth Fund estimates that 85 mil- 
lion people may be uninsured at some 
point in any gi\-en three-year period and 
that tens of millions more are signifi- 
cantly underinsured, meaning their cov- 
erage has major gaps, such as for mental 
health services, medications, or pre- 
existing conditions. 

Our Lnter^•iews with uninsured people 
supported the Institute of Medicine 
data: Being uninsured absolutely matters 
when you are trying to obtain all the 
health care you need. While it is true 
that hospitals by law must diagnose and 
treat immediately life-threatening ill- 
nesses and injuries and respond to the 
imminent dehvery of a baby, this man- 
date excludes many conditions. Over and 



16 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




over again wc found the uninsured had 
difficulty getting preventi\e services; 
controlling chronic diseases, such as 
diabetes and asthma; or even managing 
serious but not emergent conditions, 
such as Gina's gallbladder disease. 

We were particularly struck by the 
problems people faced getting dental 
care. Nearly everyone we interviewed 
had lost several teeth; some had c\cn 
resorted to pulling them out themseKes 
to stop the pain. Similarly, ment;.il health 
treatment was an issue for almost ev-ery- 
one. Ironically, the system wouldn't pro- 
\ide e\'cn a few dollars for a doctor's visit 
or medications to manage hyperten 
sion or diabetes until those conditions 
reached a critical point, such as causing 
kidney failure or irreversible disability. 
Only at this end stage would people 
become eligible for Medicare benefits. 

E\'en when people received care in an 
emergency room, they were often billed. 
Indeed, nearly everyone we met owed 
thousands or even tens of thousands of 
dollars to a hospital or doctor. Many 
fielded calls daily from collection agen- 
cies and had watched their medical debts 
ruin their credit ratings. 




We weren't surprised to find these 
detrimental effects among the unin 
sured, but we found striking the effect 
uninsurance was having on society as a 
whole. A bedrock principle of the Amer- 
ican Dream is the promise of a better life. 
If we work hard and play by the rules, 
we feel, we ha\'e a chance to get ahead, 
regardless of who we are. We discovered 
that the issue of uninsurance was seri- 
ously undermining this possibility of 
upward mobility and, indeed, was caus 
ing a growing number of Americans to 
become stuck at the bottom. 

In our book Uninsured in America: Life and 
Death in the Land of Opportunity, we describe 
this phenomenon as a "death spiral," 
created because almost alone among 
advanced countries the United States 
structurally links health insurance to 
employment. As the Institute of Medi- 
cine data show, having health insurance 
carries a strong link to being healthy. 
But we also know that being healthy 
makes you more likely to have and keep 
a job, particularly one that provides 
health insurance. Thus we have created 
a circular dependency, which, if one part 
starts to fail, leads to a downward spiral. 



We met several people, for example, 
who had lost a job — and thus health co\' 
erage — because of a layoff or a need to 
stay at home to care for a loved one. 
Without insurance, health problems — 
particularly chronic ones — worsened, 
making it harder to find employment and 
impossible to regain health insurance. 
We met many others whose descent into 
the spiral began with an Ulness that 
caused them to stop working, a particu 
larly common occurrence among people 
with mental illnesses. Unemployment 
led them to lose their health coverage pre 
cisely when they needed it most, causing 
them to get sicker and become less able to 
regain their jobs and insurance. 

For society, the result of this death spi 
ral is what we call the "caste of the ill, 
infirm, and marginally employed." We 
u.se "ca,ste" intentionally because unlike 
"class" it connotes permanency. Se\'eral 
factors conspire to solidify this status. 
The first is the person's general health 
status — it's difficult to land a job if you're 
sick. The second is personal appearance. 
Being uninsured leaves physical marks 
over time: poor skin, limps, chronic 
coughs, and, most commonly, poor teeth. 



The crisis of the uninsured is too often 
and while this is important, we must not forget 



Because of these physical difficulties 
many people at the bottom of the spiral 
cannot get employment that involves 
face to-face contact; instead, they are 
forced into jobs that typically do not 
provide health coverage. The third and 
final issue is debt burden. Medical debt 
locks people into this caste. With ruined 
credit ratings they cannot acquire cred- 
it cards, buy houses or cars, or even rent 
new apartments. 

BREAKING THE LINK 

Experts in this country have offered no 
shortage of proposals for taclding the 
issue of the uninsured. Nearly all major 
advocacy groups and national pohtical 
candidates have put forward plans. 
The goal of our project was not to add 
another proposal to the mix, but to 
evaluate what was already on the table. 

Most of the current debate in 
Washington and in state capitals 
revolves around incremental solutions, 
whether expanding existing public 
programs such as Medicare or Medi- 
caid or mandating that employers 
cover individuals. The problem is that 
none addresses the root cause of the 
death spiral: the link between employ- 
ment and health insurance. This link 
may have made sense in an era when 
health coverage was inexpensive and 
people typically worked for the same 
company throughout their careers, but 
in an era of rising health care costs, 
transient patterns of employment, and 
the pressures of global competition, it 
has become obsolete. 

Those on both ends of the political 
spectrum agree that we need to break 
the link between employment and 
insurance; what they argue about is 
how to do so. One way is to make 
health insurance a private matter, 
with individuals left to purchase cov- 
erage on their own — much as we now 
fund our retirements with 401(k) 
plans. The problem, of course, is that 
while this model would work for 
those who are educated and well off. 



it would leave those like Gina behind, 
unable to afford the premiums for pri- 
vate coverage. 

An alternative would be to make 
health insurance the government's 
responsibility, and, like Canada, move 
to a single-payer system. Although this 
approach would dramatically reduce the 
bloated overhead in our current health 
care system — and be far more equi- 
table — many fear such a plan would 
lead to long waiting lists for elective 
procedures, similar to what occurs in 
many other countries, and would ham- 
per future health care innovation. 

The solution likely lies somewhere 
in the middle. A possible analogy can 



be found in how we deal with prima- 
ry and secondary education in this 
country. From before the Revolution- 
ary War, we have believed that educa- 
tion is good not just for indi\ iduals 
but also for society as a whole. Thus 
we make the provision of education 
to children a public rather than pri- 
vate responsibility. 

We do not, however, make this the 
only way to obtain an education. 
Parents can choose to pay for their 
children to attend private schools, 
tutoring programs, and a host of other 
educational options. This system 
allows for the diversity and innova- 
tion that seem critical to U.S. culture. 



A Larger Frame 

The debate over how to respond to the crisis of the uninsured usually centers on alter- 
native models for financing health care. But many argue that we need to think bigger 
before we can truly address the health care needs of the underserved. 

Tackling the issue of the uninsured may mean radically changing not only how 
health care is financed but also how it is delivered. Perhaps the primary problem is 
not really coverage, but cost. Mark Smith, chief executive officer of the California 
Healthcare Foundation, argues that as long as health care costs about $6,000 per 
person per year, we will never muster the political will to spend that much for each 
person in the United States. If we could deliver good care for half that, though, the 
task would become less daunting. 

During the past year I have been working with Arnold Milstein of Mercer Consulting, 
the California HealthCare Foundation, and others on the Bug Project, an initiative aimed 
at designing a new health care model that delivers better quality of care to the under- 
served at half the current cost. Focusing on the sickest 20 percent of this population, our 
model combines high-intensit/, proactive health management with a great deal of care 
and education by phone and email, information-technology-enabled physician visits 
when necessary, and evidence-based referrals to specialists and tertiary core practition- 
ers. By increasing the investment in well-designed primary care, we hope to improve 
quality and decrease overall spending. We are now assembling a cohort of institutions 
to test and refine our model. 

Even this sort of wholesale redesign may not suffice, however. Our visits to places 
with large populations of uninsured people convinced us that the problems stretch 
beyond health care. Even if uninsured people received health insurance, many would 
still be unable to access care because they lack providers, transportation, childcare, or 
a command of the English language. In addition, many of the health problems the unin- 
sured experience are exacerbated — if not caused— by limited access to nutritious food 
and safe places to exercise, poor educational opportunities and jobs, polluted living 
conditions, and generally high levels of stress. Although none of these issues should pre- 
vent us from seeking ways to provide better health care for the uninsured, each should 
motivate us to think more broadly about the types of interventions needed. 



18 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



couched in the language of economics, 
that the issue is a deeply moral one as well. 




Although one can certainly argue that 
grave disparities in quality exist among 
different kinds of schools, those gaps 
are considerably smaller than the gaps 
in health care coverage. 

The current situation must be changed. 
My lasting response to all our inter^ 
views was one of shame — shame that 
such a rich nation can allow so many of 
its citizens to suffer because of an obvi 
ously broken system. The crisis of the 
uninsured is too often couched in the 
language of economics, and while this 
is certainly an important aspect, we 
must not forget that the issue is a 
deeply moral one as well. 

We noticed that Gina, the styHst at 
FabuCuts, tried to keep her mouth 
closed even while speaking. When asked 



why, she explained that a ca\'ity was rot 
ting away one of her front teeth because 
she hadn't been able to afford dental care 
for three years. "You see," she said, "there's 
a hole there, and I've ne\er had one there 
before." Gina was embarrassed; because 
of her teeth, she was beginning to look 
like a member of the caste of the ill, 
infirm, and marginally employed. 

We must do better to create a system 
in which hard- working people like Gina 
can take care of their health issues — and 
have a shot at upward mobility. When 
we turned to leave and told Gina again 
that we couldn't see the gap in her 
teeth unless we practically stuck our 
heads into her mouth, she broke out in 
a grin that lit up the entire room. For a 
moment, her pain and stress receded, and 



she beamed a thousand watts of delight. 
Plain Gina turned into the beautiful 
young woman she is, and should be. ■ 

Rushiha Fcmandopidle '94 is an internist on staff 
at Massachusetts General Hospital He was the 
first executive director of the Harvard Interfacul 
ty Program for Health S\'sft'ms Improvenyent and 
is cofounder of Renaissance Health, an innovative 
primary care practice in Arlington. Massachu 
setts. He can be reached at rf^renhealthnet. 

Ginas story was taken from the recent book 
Femandopulle coauthored with Susan Starr Sercd, 
Uninsured in America: Life and Death 
in the Land of Opportunity (UMivcrsitv o) 
California Press. Berkeley. 2005). While Gina's 
story is real, her name and some details of her life 
have been changed to protect hcrprivacv 



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SPECIAL REPORT: THE UNINSURED 




What will it take to wake 
the nation up to the need 
;:or universal health coverage? 



BY PAT MCCAFFREY 






— ^ ITH MORE THAN 45 MILLION UNINSURED AND 

an additional 20 million considered 
underinsured, the United States remains 
one of the few industrialized countries 
without universal health coverage. At 
the same time, we spend more per capita than any other 
country on medical services, and costs are rising rapidly. 
Yet issues of access and equality in health care barely catch 
the attention of the general public or politicians, with the 
exception of daily reporting on the confusion and anxiety 
surrounding the new prescription drug benefit for those 
on Medicare. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



The option — to remain one of the few 
world that does not cover everyone as a matter 



We asked experts on health care dehvery 
and pohcy, drawn from the ranks of Har- 
vard Medical School's alumni and facul- 
ty, what it would take to achieve some 
form of uni\'ersal health coverage in the 
United States. Their forecast, to a person, 
is for stormy weather ahead, followed by 
clearing. Most beheve the situation will 
get worse, perhaps much worse, before 
significant change occurs. Escalating 
difficulties for businesses, middle-class 
workers, and physicians are predicted. 
When the storm passes, its aftermath 
should yield a more equitable, more effi- 
cient, and possibly even cheaper system. 
But until then, the experts say, hold on 
because we're in for severe turbulence. 



Despite differing visions of what the 
end product should be, our contributors 
all strongly agreed that we must reach 
the goal of universal coverage. To some, 
getting there means tweaking our cur- 
rent system to create an entry point for 
every person, whether young or old, rich 
or poor, self-employed or unemployed. 
But to others, achieving universal cov- 
erage means a dramatic restructuring 
toward a single -payer, government-spon- 
sored plan, with little or no role for pri- 
vate insurers. 

Whether change comes incremental- 
ly or all at once, whether the solution is 
a single payer or a patchwork of private 
programs, the hurdles are much the same. 



The escalating cost of medical care, 
opposition to new taxes, lack of politi- 
cal will and leadership, tepid public 
support, and the entrenched interests of 
labor, business, insurance agencies, and 
pharmaceutical companies all present 
formidable roadblocks to achiexing uni- 
versal health insurance. 

The option — to remain one of the few 
industrialized countries in the world 
that does not co\'er ex^eryone as a matter 
of course — seems unimaginable. So we 
asked the experts to exercise their 
imaginations and describe scenarios in 
which our society could be pushed to a 
tipping point that would make univer- 
sal coverage inexitable. 




I 



22 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



industrialized countries in the 
of course — seems unimaginable. 



FATE OF THE UNION 

Today, political interest in universal 
health coverage is at ebb. Periodically, 
though, the issue gathers steam, most 
recently in the early 1990s. We all 
remember the winning mantra of the 
1992 presidential race: "It's the econo 
my, stupid." Unknown to many, how 
ever, was the next bullet point on Bill 
Clinton's agenda during that campaign: 
"Don't forget health care." 

What followed that election — the 
flurry surrounding the Clintons' health 
care proposal and its utter failure — sue 
ceeded in knocking health care off the 
national agenda, a situation that persists. 

"Politicians have considered the 
health care issue to be like the third 
rail, something to avoid at all costs," 
says James Bernstein '52, a retired gas- 
troenterologist and past president of 
the Long Island Coalition for a Nation- 
al Heath Plan. Bernstein is active in 
educating physicians and lobbying leg- 
islators for a single-payer national 
health insurance system. 

The plan Bernstein and 13,000 other 
doctors support was outUned by the 
Physicians for a National Health Pro- 
gram in the August 2003 issue of the 
Jounwl of (he American Medical Association. 
The plan resembles Medicare, with the 
federal government buying medical ser-^ 
vices and supphes for all citizens from 
private providers. Drafted into a legisla- 
tive proposal sponsored by U.S. Repre- 
sentative John Conyers, Jr., a Democrat 
from Michigan, the bill has attracted 62 
cosponsors. But that plan, or any other 
with a chance of making a significant 
difference for the uninsured population, 
is unlikely to succeed anytime soon. 

Ideology and the current political 
climate are both contributing to the 
problem, Bernstein says. "The Bush 
administration isn't in favor of any 
domestic program that doesn't benefit 
the rich. So they're not interested in 



doing anything fundamental to cure 
the health care crisis." 

Universal coverage, whether single 
payer or some other configuration, 
would mean an increase in taxes, and 
politicians and the public will need to 
face that reality, says Thomas Lee, Jr., 
HMS professor of medicine and net- 
work president for Partners Health- 
Care in Boston. "My optimistic sce- 
nario for universal coverage is that we 
have good leadership, which helps us 
confront the question of just how gen 
erous we are as a nation. Are we will 
ing to let people within our eyesight, 
or just out of our field of vision, go 
without insurance? Or are we ready to 
pay more taxes and provide coverage 
for everyone? I think universal cover- 
age is possible with good leadership. 
That, of course, means waiting until the 
next presidential election, at least." 

Steffie Woolhandler, HMS associate 
professor of medicine at Cambridge 
Hospital, cofounder of Physicians for a 
National Health Program, and a vocal 
advocate for a single payer system, 
believes political movement could start 
with one charismatic leader. "If there 
were a congressional candidate," she 
says, "who ran on a national health 
insurance platform and won unexpect- 
edly — that could provide the kind of 
breakthrough that gets everyone talk- 
ing about health care again." 

Woolhandler points to the example 
of Democrat Harris Wofford, who 
defeated heavily favored Republican 
Richard Thornburgh in the 1991 U.S. 
Senate race in Pennsylvania. "In the 
last few weeks of the campaign, 
Thornburgh ran TV ads all over Penn- 
sylvania saying Wofford supported 
socialized medicine and a single-payer 
system," Woolhandler says. "Well, lo 
and behold, Wofford won. It was a real 
breakthrough. I was in Washington at 
the time, and it felt like a lightning 



HOW DID WE GET 
INTO THIS MESS? 

The U.S. health insurance system is confusing, 
complicafed, and inconsistent — a harsh state of 
offairs that can be better understood by looking 
backward. Through the lens of history, our lack of 
universal coverage, nearly alone among industri- 
alized countries, appears surprisingly inevitable. 

Franklin Delano Roosevelt first proposed uni- 
versal health care in his Social Security Act of 
1935. Yet he quickly dropped this feature of the 
act because of its high expense — and the efforts 
of the American Medical Association to scuttle the 
idea. Even back in the 1930s, the costs of health 
care coverage appeared formidable, and the 
lock of political w\\\ to transfer those costs to tax- 
payers became a major limiting factor in the gov- 
ernment's playing a sizable role in such a system. 

In the 1 950s, two events conspired to thwart 
universal coverage and to foster growth of a pri- 
vate health insurance market. Labor unions, recog- 
nizing the burden that health care costs placed on 
their members, began to bargain for health insur- 
ance. At the same time, the National Labor Rela- 
tions Board ruled that health insurance was a fringe 
benefit and therefore not subject to taxation. As a 
result, the private health insurance market explod- 
ed, and employer-sponsored private health insur- 
ance became the foundation of our current system. 

With the rapid success of the private health 
insurance market, attention soon turned to the 
inadequacies of existing coverage, shortfalls 
exacerbated by escalating health care costs. 
Also under scrutiny was the plight of those not 
covered — the poor, disabled, unemployed, and 
retired, who couldn't take advantage of the grow- 
ing number of services and therapies available. 

In response to this glaring social disparity, leg- 
islators began incrementally addressing the health 
care needs of vulnerable populations. Each step — 
including the Social Security Disability Insurance 
law passed in 1956 and the Medicare law 
passed in 1965 — ^wos helped along by Social 
Security's immense popularity and bipartisan sup- 
port. In Universal Coverage: The Elusive Quest for 
National Health Insurance (University of Michigan 
Press, 2005), author Rich Mayes notes that, in the 
1 960s and 1 970s, both administrators and legis- 

continued on page 25 



"If physicians were to acknowledge 
and join with other forces, they could make 



bolt coming down from the sky, with 
everyone suddenly understanding the 
importance of health care reform and 
the real political possibility of winning 
support with a national health insur 
ance plan." 

As it turned out, that election fore- 
shadowed Clinton's win in 1992. "I 
wasn't happy with the ultimate result 
of his proposed health care plan, which 
was nothing," Woolhandler says, "but 
that Wofford election is why the politi- 
cal debate really heated up and pro- 
pelled much of the Clinton discussion." 

LABOR PAINS 

A second trigger for a drastic change in 
policy, Woolhandler says, could be a 
spectacular business failure invohing a 
major U.S. corporation. General Motors, 
for example, now spends roughly Sl,500 
per car to provide health coverage to its 
workers, both active and retired. "In the 
auto industry," Woolhandler says, "peo- 
ple are saying GM might go under. If 
the entire company is at risk, will it 
maintain an ideological opposition to a 
reform that could actually save the busi- 
ness?" The failure of a major automaker, 
Woolhandler believes, might begin the 
end of the uniquely American system of 
employer-based health insurance and 
clear some obstacles to a more compre- 
hensive program. 

Or perhaps employer-sponsored 
health care could go out with a whim- 
per rather than a bang, \\ath a progres- 
sion of smaller corporate crises. "If Ford 
and General Motors continue to teeter, 
and if policymakers recognize that a big 
part of the cause is an out-of-control 
health care system, one result could be 
an abrogation of employer-based health 
care," says Donald Berwick '72, presi- 
dent and chief executive officer of the 
Institute for Healthcare Improvement 
in Cambridge. "The car makers could 
conceivably turn to government and say. 
This isn't our job.' " 

Although Berwick concedes that this 
scenario is unlikely, he notes that when 



General Motors discovers that a key 
engine part can be made less expensive- 
ly in another country, its representa- 
tives find a way either to buy it or to 
produce it more cheaply themselves. 
"When it comes to health care, other 
countries have created systems identi 
cal to ours, or even better, at half the 
cost," he says. "Industry leaders have 
not yet mapped that idea into their 
corporate plans, and I don't know why 
they haven't. In communities where a 




small number of employers buy most of 
the care, for example, they could insist 
on a redistribution of resources to 
achieve a better system." 

FALLING DOWN ON THE JOB 

The specter of employers dropping 
health coverage raises the most talked 
about scenario for change. In short, this 
version predicts the situation \\ill get so 
bad for the average citizen that a nation- 
wide popular movement will spring up, 
and public opinion will drive political 
action toward universal coverage. 

Unfortunately, as it stands today, the 
lack of universal health care dispropor 
tionately affects the poor, and the poor 
tend not to vote. The elderlv do, and 



they ha\'e succeeded in increasing the 
government's role in health care for 
themsehes. That leaves the people in 
the middle, says David Blumenthal '74, 
director of the Institute for Health PoU- 
cy at Massachusetts General Hospital. 

"Realistically, what we need is much 
more pain and suffering on the part of 
currently covered populations that are 
politically influential," Blumenthal says. 
"It's a matter of cost and benefit. In 
order to tolerate major changes in pub- 
lic policy, especially changes that might 
invoh'e a greater role for government, 
Americans will need to feel pretty des- 
perate. Once they've lost faith in the 
current system, once they realize it isn't 
meeting their needs, they'll be willing to 
walk the plank to a new way of relating 
to the health care system." 

Is there a critical number of unin- 
sured required to tip the balance? "It's 
clearly not 16 percent of the popula- 
tion," Blumenthal says. "It may be more 
like 25 percent. It has to be a substantial 
number of employed people who can't 
sleep at night because they're afraid 
their insurance will soon disappear." 

Talmadge King, Jr. '74, chief of med- 
ical services at San Francisco General 
Hospital, had once predicted a thresh- 
old of 40 million uninsured, then 
watched that threshold pass se\eral years 
ago. "I thought when the number 
reached 40 million the pressure would 
be so great we'd be forced to deal with 
it," he says. "But we're still skating by. 
I'm not sure what the number will have 
to be before enough people get upset 
about our current crisis." 

At his hospital. King has noticed 
what he calls a "not-so-subtle shift" in 
the kinds of patients he encounters. 
"We've always taken care of the work- 
ing poor," he says, "but the range of 
working poor has expanded. We usual- 
ly see restaurant workers and day labor- 
ers. But now we also see high school 
teachers, department store clerks, and 
humane societ)' employees. We wouldn't 
have seen these people in the past 



24 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



some solutions to the problem 
a huse difference." 



because they carried insurance. But 
they're no longer covered." 

King predicts that one stimulus for 
change will be the growing discontent 
of doctors. "Physicians whine, but in 
fact medicine is still an outstanding 
career," he says. "When the erosion of 
the profession reaches a certain point, 
though, the conversation will begin 
again nationally. Right now no one 
wants to talk about it." 

Some physicians arc talking about 
it, however. In one widely publicized 
2004 study by Woolhandler and col 
leagues, a random poll of Massachu 
setts doctors revealed that two out of 
three believed a single- payer solution 
would be best for their patients. 
Whether that result translates nation- 
wide remains to be seen, but Woolhan- 
dler is working hard to mobilize physi- 
cians as advocates for the single-payer 
system. Meanwhile, the American Med- 
ical Association has taken a different 
tack, favoring government support of 
private insurance plans to achieve uni 
versal coverage. 

Whate\'er their \iews of the best solu 
tion, physicians ha\'e a special role to play 
in the struggle toward uni\-ersal co\'er- 
age, says Rashi Fein, HMS professor of 
the economics of medicine, emeritus. 
"Doctors can play a tremendous role," he 
says, "because despite all the complaints 
about the medical care system, despite 
all the concern about conflict of interest, 
the general public beheves in the author 
ity of doctors. If physicians were to 
acknowledge some solutions to the 
problem and join with other forces, such 
as the business community, they could 
make a huge difference." 

WAITING TO UNVEIL 

An important precondition for achie\-- 
ing universal coverage, no matter its 
final details, will be the public's accep- 
tance and admission that everyone in 
the nation is entitled to health care. 
Health care must be seen as a common 
good, similar to education, explains 



Berwick. "Countries that offer univer- 
sal coverage as a matter of poHcy under 
stand that. As step one, Americans 
should immediately acknowledge health 
care as a human right." 

Next, everyone should understand 
that despite its complexities, the goal 
of achieving universal coverage in the 
United States presents no insur- 
mountable technical problem. Says 
Fein, who teamed with former U.S. 
Surgeon General Julius Richmond to 
write The Health Care Mess: How We Got 
Into It and What It Will Jake To Get Out 
(Harvard University Press, 2005), "It's 
not a problem of our not knowing how- 
to do it. There are enough models out 
there, and we are bright enough to 
figure out which ones can be adapted 
to our circumstances." 

An examination ot the experience 
with Medicare may show the way for 
ward, according to Fein. "Medicare 
took eight years from the time it was 
introduced to the time it was passed," 
he says. "Every year the committees 
\'oted it down, and it always popped 
back on the agenda the following year. 
It kept returning in no small measure 
because of the persistence of senior citi- 
zen groups and concerted efforts to 
educate the public on the issue. There 
was organization, and there was deter- 
mination. The Chnton program, in great 
contrast, was offered just once." Fein 
pauses. "And you ne\er heard anything 
about it again." 

"What's required," Fein adds, "is a 
process in which this issue stays on the 
agenda long enough to educate members 
of the public, to get them to understand 
the importance of universal coverage, to 
allow them to assess the wisdom of 
different approaches. Eventually, achie\- 
ing universal coverage won't be a top 
down process; it's going to come from 
the grassroots. It's time to resume 
the debate." ■ 

Par McCaffrey is a freelance writer based in 
Auburndale, Massachusetts. 



continued from page 23 

lators believed the incremental approach would 

eventually lead to universal coverage. 

Ironically, it v/as a Republican president, 
Richard Nixon, who brought the United States the 
closest it has been to universal coverage. Nixon's 
efforts in the early 1 970s were opposed and ulti- 
mately dismantled by unions and by prominent 
Democrats who believed his plan didn't go far 
enough. Nonetheless, his administration's expan- 
sion of benefits led to a dramatic acceleration of 
health care costs borne by the federal government. 
Some have argued that it is the escalating expense 
that makes further expansion of benefits more diffi- 
cult: How can we add more benefits when we 
can't afford the ones already on the books? 

The 1 990s gave us the failed health reform 
plan proposed by the Clinton administration. 
With a structure devised by a host of health pol- 
icy experts, politics proved its undoing. No 
matter how well conceived, the Clinton plan 
was doomed because it didn't provide opposi- 
tion lawmakers with sufficient incentives to sign 
on to it. The health insurance lobby played a 
key role in the demise of the plan as well. 

The Medicare Modernization Act, which 
took effect in 2004, dramatically expanded 
benefits. With federal coverage for medica- 
tions, benefits once again increased — but con- 
cerns about costs produced a convoluted bene- 
fit structure. In addition, lobbying by the phar- 
maceutical industry removed the most obvious 
opportunity for effective cost containment — the 
ability to negotiate drug prices. 

Several states are now poised to provide uni- 
versal coverage to children. This appears to be 
the next incremental step toward universal cover- 
age. Covering children is attractive because it is 
relatively inexpensive. Nonetheless, as we look 
bock through the past six decades, each attempt 
to expand health care coverage has been 
blocked or limited by the efforts of self-interested 
groups — including doctors, hospitals, insurance 
companies, and the pharmaceutical industry — to 
maximize their own slice of the pie. Further 
progress may only be achieved when all entities 
in the medical care delivery system step back 
from a position of maximizing their own income. 
Maybe they can be encouraged to see a greater 
good for all Americans: universal coverage. ■ 



Timothy G. Ferris '92 is an HMS assistant 
professor of medicine and pediatrics at Massa- 
chusetts General Hospital. 



SPECIAL REPORT: THE UNINSURED 



For people without health 
insurance, a serious illness 
can start a downward 
spiral that may even lead 
to homelessness. 



Preachin 




BY JAMES J. O'CONNELL 



26 I HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




X, 




LATE ONE WINTER WE GATHERED IN THE BASEMENT OF 
St. Anthony Shrine in the heart of Boston to 
remember a man whose stubborn charm had 
enchanted and exasperated us during his two 
decades on the streets of our city. Three days 
after Christmas, in frigid and snowy weather, he was found 
near midnight on a cement bench two blocks from Massa- 
chusetts General Hospital with a core body temperature of 
78 T. Earlier that evening our team had pleaded with him to 
go to a shelter, but he had insisted he was fine. His cause of 
death remains uncertain; he likely suffered a seizure in the 
hours before he was found. Heroic measures to warm him in 
the emergency room with heated saline and bilateral chest 
tubes failed to restore a heart rhythm. 



During our subterranean ceremony, we 
sang to piano, guitar, and trumpet accom- 
paniment; read Old Testament stories 
and poems of loss and hope; and alter- 
nated tears and chuckles as we shared 
stories. Assembled was the man's wide 
circle of caregivers: emergency-room 
nurses and social workers, outreach 
street workers, therapists, and our own 
street team of doctors. This ebullient 
man had logged a legendary number of 
visits to the MGH emergency room, 
earning him a \irtually permanent gur- 
ney in the hallway. He al\\'ays blew kiss- 
es to the nurses, graciously accepted all 
meals, and offered profound thanks to 
anyone who cared for him. He was on a 
first-name basis with the staff of the 
emergency- service team of the Massa- 
chusetts Department of Mental Health. 
The nurses at a local dual-diagnosis unit 
lamented the loss of a man who had tried 
literally hundreds of detoxifications but 
never managed to achieve more than a 
few weeks of sobriety. We couldn't help 
but share a single sad obser\'ation: if only 
he had realized during his lonely decades 
on the streets the number of hves he had 
touched and how many people would 
gather to celebrate his life and memory. 

I last saw him four days before his 
death, as I was finishing rounds at MGH 



on Christmas Eve. I got off the elevator 
on one of the clinical floors and found 
him sitting proudly by the window in the 
small lobby area, looking off toward the 
frigid Charles River as he ate a turkey 
dirmer. A nurse who had befriended him 
during his innumerable admissions had 
seen him alone in the main hospital 
lobby and had coaxed him up to the 
floor for a meal and a flurry of attention 
by the other nurses and the medical 
team. He was ecstatic and grateful. 

"The mashed potatoes are lumpy 
and no turnips tonight," he told me. 
"But this turkey would be succulent 
with a little chardonnay!" 

His shoes were warming on the radia- 
tor, and his swoUen feet were a podiatrist's 
textbook; hammer toes, bunions, stasis 
dermatitis, old frostbite, onychomycosis, 
and the marked Uchenification and pitting 
typical of immersion foot. The stench was 
stultifying, and the e\'ening xisitors kept 
a wide berth. I invited him to spend the 
holiday at our care facility for the home- 
less, but he declined with an expansive 
gesture; he had all he needed for now. 

We knew he was a 49-year-old Air 
Force \'eteran and a former high school 
hockey star, but other than those details 
his past was shrouded in m)'stery. He had 
once admitted that he had been married 




and had lost contact with his two chil- 
dren. After his death, though, we could 
find no family members, and his hulking 
body remained unclaimed in the city 
morgue for the requisite six months 
before cremation and internment in a 
paupers' field. He had navigated the 
labyrinth of our medical, mental health, 
and substance abuse systems without 
health insurance, exposing our inabiht}' 
to communicate across systems w^tule 
relegating him to frequent use of our 
emergency rooms, acute psychiatry ser- 
vices, and detoxification units. 

Homelessness magnifies poor health, 
exposes those huddled in crowded 



28 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 







m 



J 



r 


V " 


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shelters to communicahle diseases 
such as tuberculosis and influenza, 
comphcates the management of chron- 
ic illnesses such as diabetes and asth- 
ma, makes health care harder to access, 
and presents vexing obstacles that 
exasperate health care providers and 
confound delivery systems. These 
problems are amplified dramatically 
by the lack of health insurance that is 
common in this impoverished group of 
our citizens. Without insurance, pre- 
vention is a distant dream, manage- 
ment of chronic illnesses becomes 
immeasurably complicated, and health 
outcomes are dismal. 



ROUGH LANDING 

The experience of illness and suffering 
among the homeless in urban and rural 
America is complex and poorly under- 
stood. This man's story is numbingly 
familiar to physicians, nurses, and 
other clinicians who witness the lone- 
ly, desperate, and often painful deaths 
of homeless men and women in our 
urban hospitals and academic medical 
centers. Death is a constant, though 
erratic, companion for people li\ing in 
shelters and on the streets. We know 
from studies in the United States and 
other countries that homeless people 
suffer mortality rates that are at least 




Behind the numbing statistics are breathtaking 
by people playing impossible hands dealt 



fourfold greater than those found in the 
general population. 

The Boston Health Care for the Home 
less Program (BHCHP), for which I work 
as a street team physician, seeks to ensure 
consistent, continuous, and high-quahty 
health care for homeless men, women, and 
children. Dedicated teams of doctors 
work with nurses, nur.se practitioners, 
physician assistants, and social workers 
in a system that integrates 70 shelters and 
outreach clinics with three hospital clin- 
ics — Boston Medical Center, Massachu- 
setts General Hospital, and Lemuel Shat 
tuck Hospital. We provide almost 10,000 
people with comprehensi\'e medical, psy- 
chiatric, and oral health care each year. 

Our model of care is predicated upon 
enduring and personal relationships 
between patients and their doctors and 
other caregivers, best initiated and nur- 
tured in familiar places far from the 
bureaucracy of hospitals and health care 
institutions. Ironically, this harkens to an 
earher era in U.S. medicine when home 
\isits were common and essential to the 
doctor's understanding of the lives and 
special situations of each patient and 
family. Life in the shelters and on the 
streets has an inescapable immediacy and 
many obstacles that render health care a 
distant priority. Appointments in clinics 
and offices are rarely successful, and doc- 
tors and other clinicians must venture 
out to visit and understand the homeless 
person's shelter and street "home." 

Rough sleepers are an eclectic group 
of resolute indixiduals who embrace a 
modern brand of rugged American indi- 
vidualism and eschew the rules and 
crowds of the shelters. Feisty and com 
plex, stubborn and uncompromising, 
these people alternately exasperate us 
and endear themselves to us. Despite 
frequent headlines and a ubiquitous 
presence on the urban American land- 
scape, the tragic li\es of these impover 
ished individuals remain obscure. Like 
Jeremiah preaching to the exiles, rough 
sleepers are modern urban nomads who 
dwell under bridges, in subway tunnels. 



and down back alleys — modern prophets 
on the fringes of society who emerge to 
rant, regale, and condemn a world gone 
astray. Many adopt biblical "street" 
names, with Isaiah, Ezekiel, and Adam 
as common first names and Zion and 
Israel as occasional last names. 

What happens to these elusi\"e rough 
sleepers o\'er the years is not known. 
Anecdotes, headlines, and stories abound; 
the science is wanting. In 2000, nearly 
250 people lived year round on the 
streets of Boston. To help understand the 
health consequences of such exposure to 
the extremes of weather, temperature, 
and violence, we chose to follow a cohort 
of almost half that number. Most had 
been living on the streets for at least 
a decade, sometimes two. One quarter 
were women. The a\'erage age was 47, 
\\ith a range of 32 to 82 years. The demo- 
graphics, including race and ethnicity, 
did not differ significantly from those of 
the general population of Boston. From 
2000 through 2004, our street team 
cared for these individuals and tracked 
their whereabouts. We lost contact with 
only five during that time, a tribute to the 
rich network of ser\ices and collabora- 
tions among ser\ice pro\'iders, ad\'Ocates, 
and city and state agencies, including 
the police, the emergency medical ser- 
vices, hospital emergency rooms, and the 
Massachusetts departments of public 
health and mental health. 

In five years, 28 percent had died and 
another 5 percent had been placed in 
nursing homes with chronic and debili 
rating illnesses. Another third had been 
placed in housing or long-term programs, 
and a final third stiU Lived on the streets. 
The causes of death were primarily chron- 
ic diseases that were often preventable, 
such as cancer, cirrhosis, obstructi\'e lung 
disease, and heart failure; only two people 
died of hypothermia and exposure. The 
group's morbidity and mortality rates 
were staggering. These outcomes repre- 
sent astonishing health care disparities 
that in another population would con 
stitute a public health emergency. 



Our hypothesis that these individuals 
had fallen through the holes in our safety 
net and avoided our health care system 
proved resoundingly wrong: the 119 indi- 
viduals in our study had an aggregate 
18,384 emergency- room visits between 
1999 and 2003. We are only beginning 
to understand the costs of neglecting 
those who live on our streets. 

Behind the numbing statistics are 
breathtaking stories of desperate courage 
by people playing impossible hands dealt 
to them b)' fate and poor luck. A 35-year- 
old man died of AIDS se\'eral years ago 
after months of suffering through repeat- 
ed bouts of pneumonia and a profound 
wasting s\Tidrome. He left innumerable 
hospitals and nursing homes to seek inde- 
pendence on the streets, only to be found 
gra\-ely iU and taken repeatedly to local 




30 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



stories of desperate courage 
to them by fate and poor luck. 



emergency rooms. We learned upon his 
death that the name he had given us was 
an ahas. Despite caring for him intensive- 
ly for more than a decade, we never 
learned his true identity, and we still 
worry that his fainily may wonder what 
happened to their son, brother, or father. 
A kind funeral director arranged a wake 
for him, a Mass was said in the inner cit\' 
church where he often slept in the alco\e, 
and he was buried in a paupers' field 
alongside thousands of others. A small 
bronze medaUion \\ith a number marks 
his gra\'e; the name associated with the 
number resides in a city hall ledger. 

RPEATHING ROOM 

One 45-year'old man in our cohort was 
apprehended for misdemeanors and held 
in the county jail for several months. 



Curt, combative, and \ituperative, he had 
nonetheless earned my respect through 
his fearlessness and noble insistence on 
being the protector of older folks on the 
streets. His approach to the world was 
explosive and confrontational, as he 
raged openly about the "lousy hand" he 
had been dealt in life. He belittled most 
of us in health care for "ne\'er listening" 
even though he frequently presented 
with a range of somatic complaints that 
resulted in exhaustive and futile e\'alua 
tions. He wrote several letters from jail 
imploring our intercession and insist- 
mg that his complaints of severe back 
pain were being ignored. 

When I \isited, I found a pale, cachec- 
tic man unable to rise from his chair with 
out sexere pain. His complaints had indeed 
gone unheeded, e\-en though a chest x-ray 




The lack of both stable housing and health 
shortcoming in the continuum of care offered 
raises substantial ethical issues. 



upon incarceration four months earlier 
had shown a suspicious lung mass and 
several collapsed vertebrae. After an 
immediate transfer to our hospital he 
requested that everything possible be 
done. His condition deteriorated rapidly, 
however, and we began a nightly \'igil in 
his room. An armed guard was constantly 
at his door, and his leg shackles remained 
in place. He sat up through the night 
gasping for breath yet refusing oxygen. 

On the day before his death, he plead- 
ed for the dignity of d)'ing without shack- 
les on his legs. After many hours of calls 
and with the help of hospital lawyers, we 
found a judge willing to release him to 
our custody. Once the shackles were 
removed, his anger and will to Uve dissi- 
pated and he died within hours. 

The lack of both stable housing and 
health insurance exposes a critical short- 
coming in the continuum of care offered 
by our country's health care system and 
raises substantial ethical and pragmatic 
issues. To bridge this gap, in 1985 the 
Robert Wood Johnson Foundation fund- 
ed health-care-for-the-homeless pro- 
grams in Boston and Washington, DC, 
to develop and implement the concept 
of "respite care." Medical care and a safe 
place to heal were offered to homeless 
people with acute short-term illnesses, 
infections, and injuries who would other- 
wise require prolonged hospitalizations 
or risk considerable harm on the streets. 

In the interim, seismic changes in 
our health care system have shifted the 
locus of care from hospital to home for 
many critical services. Drastic reduc- 
tions in hospital lengths of stay, the 
astonishing evolution of anesthesia and 
minimally invasi\'e day surgery, and the 
shift in specialty services from hospital 
to outpatient clinic for such treatments 
as chemotherapy have resulted in a dra 
matic increase not only in the demand 
for respite beds but also in the acuity 
and the complexity of the medical needs 
of people referred for respite care. 

In 1993, BHCHP moved the original 
respite-care program of 25 beds nested 



within a local shelter to the Barbara 
Mclnnis House, a free-standing former 
nursing home that now has 90 beds with 
24-hour medicd and nursing care. This 
program offers acute, subacute, preoper- 
ative, postoperative, recuperative, reha- 
bilitative, palliative, and end-of-life care 
to homeless people throughout Massa- 
chusetts. Referrals come from emergency 
departments, hospital inpatient units, 
primary care and specialty clinics, and 
BHCHP staff in shelters and on the 
streets. The demand remains intense and 
overwhelming; the waiting hst is cum- 
bersome and discouraging. 

Mclnnis House often becomes the 
venue for the deaths of many rough 
sleepers who are without fanulies or 
insurance. As they provide care to dying 
homeless people, our nurses and doctors 
tread that fine line between caregiver 
and family member. 

Several years ago we diagnosed an 
undocumented 42'year-old man from 
Central America with a leiomyosarcoma. 
A tireless worker at a local thoroughbred 
racetrack, he Uved in a barn on the back- 
stretch and sent half of his meager wages 
to his impoverished family. With no place 
to go and no health insurance other than 
the state's uncompensated care pool, he 
was admitted to Mclnnis House after his 
initial surgery and remained there while 
he underwent monthly chemotherapy 
that left him frail and fatigued. 

The man's response to treatment was 
disappointingly brief and his medical and 
nursing care became intense as he weak- 
ened. We referred him to a skilled nurs- 
ing facihty for hospice care. This taciturn 
man tearfully pleaded to stay in the place 
he felt safe and accepted. We couldn't 
send him away. Nearly everyone on staff 
volunteered to take turns sitting with 
him at night to monitor his pain, help him 
to the commode, and ease his dread of 
being alone. Hospice nurses came to 
Mclnnis House to assist with his care and 
to educate us in end-of-life care. He died 
peacefully and with minimal pain two 
months later. The time and intensity of 



these efforts were exhausting and created 
considerable tension within an already 
beleaguered staff. Yet we were all grateful 
for the opportunity. Perhaps most pro- 
foundly, his d)ing allayed the fears of our 
patients; they realized we would not 
abandon them at the time of death. 

Each death has posed new challenges. 
A 50-year-old \ietnam veteran who spent 
20 years li\ing in the Boston Common 
developed head and neck cancer soon 
after celebrating a year of sobriety. His 
medical odyssey included a sequence of 
progressively more radical surgical pro- 
cedures after he failed to respond to radi- 
ation therapy and chemotherapy. He 
eventually lost his tongue and most of 
his mandible. Time outside the hospital 
was spent in our respite-care program, 
where he stubbornly managed his own 
tracheostomy care while continuing to 
smoke in the courtyard. 

A deepening depression, explosive 
outbursts over innocuous comments by 
other patients, and an escalating depen- 
dency on opiates for pain control became 
contentious and frightening, and he was 
eventually transferred to a nursing home 
for the last three months of his life. We 
would visit him regularly, enduring his 
wTath if we missed a day or failed to bring 
cigarettes. Unable to muster even a gri- 
mace of thanks with his disfigured face, 
he left a poem of hope and gratitude in his 
bedside drawer to be read at his funeral. 

Rough sleepers ha\'e been exiled to the 
fringes of our cities, where the streets 
are desperate, lonely, and deadly. These 
prophets and \isionaries gone astray illu- 
minate the failures of many sectors of our 
society, including housing, health, edu- 
cation, welfare, labor, and corrections. 
Choices and options for these indi\idu- 
als Yiaxe been limited by the ravages of 
poverty, iUiteracy, mental illness, addic- 
tions, and chronic medical illnesses. 
These cries from the urban desert should 
rattle our foundations. ■ 

]amcs]. O'Comdl '82 is president of the Boston 

Health Care for the Homeless Program. 



32 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



insurance exposes a critical 
by our health care system and 



V 






-SiZiS* 



HIDDEN DEPTHS: 
Although many health 
problems reported by 
people who are home- 
less mirror those in the 
larger population, the 
health concerns of the 
homeless are often 
compounded by mental 
illness, substance 
abuse, or both. 



u 


X 


Unchartel] 


h 


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TRACKING THE STORM 




THE SCENE MIGHT HAVE APPEALED TO A FILMMAKER! SEVERAL HUNDRED 

officials closeted, focused on an event whose proportions stretched 
comprehension. Under discussion was a plan for dealing with Hur- 
ricane Pam, a slow-moving Category 3 hurricane that would batter 
the Gulf Coast with a 20-foot storm surge and breach the levees 
shielding New Orleans from the waters of the Gulf of Mexico. ^ Pam, 
though, was conjured; a scenario constructed for practice and plan- 
ning. A year later, the real thing hit town: Katrina. Her swift pace 
and backdoor breach of the levees swamped the plan and stymied 
the planners. '©^ Katrina came ashore the morning of August 29 and 
swept east, leaving a swath of inland destruction roughly the size 
of the United Kingdom. Her ferocity will likely remove her name 




from the list for future tropical 
storms — but not from the memory of 
Gulf Coast residents. Katrina left five 
million of those residents without 
power. She left several times that num- 
ber powerless. 

The Katrina calamity has claimed 
more than 1,300 Uves, added more than 
3,240 names to the nation s list of miss- 
ing, forced more than a million resi- 
dents from their homes, and delivered a 
punch to the region's economic gut that 
has left the area gasping for nearly S200 
billion to aid in its recovery. 

Among the witnesses to Katrinas 
destruction were Harvard Medical School 
alumni. Working at New Orleans's 
"Big Charity" throughout the disaster, 
Ruth Berggren '88 lived the fear, frus- 
tration, and fatigue that embraced the 
patients, staff, and medical profession- 
als marooned first by the storm, then by 
Gulf waters. In Biloxi, Anthony Lamar 
Mitchell '98 faced the stress and uncer- 
tainty that came with working non- 
stop for long hours under daunting 
conditions and shifting circumstances. 
In Houston and Baton Rouge, Maurice 
Sholas '95 experienced the pain and 
isolation of the refugee — and the dis- 
tress of doing all he could but less than 
he wanted. 



Big Charity in the Big Easy 

"Announce yourself," Ruth Berggren 
heard the nurse call out. 

It was Thursday night, the tail of 
another tough day for Berggren, and she 
was tr)'ing to catch some sleep. A httle 
before noon, efforts by the National 
Guard to evacuate patients through Char- 
it)' Hospital's emergency room had stalled 
when a man, from a perch in a nearby 
parking garage, shot at staff, patients, and 
would-be rescuers. The group of prospec- 
tive rescuers included Berggren's hus- 
band, Tyler Curiel, who had only recently 
canoed over from Tulane University Hos- 
pital, adding another doctor to Berggren's 
roster and bringing some welcome food 
to the ward's depleted stores. Yelling 
"Sniper, sniper!" the crowd in the loading 
area stampeded past Berggren, nearly 
knocking her down. 

Twenty minutes later, another sniper, 
this time targeting the rear of the hospi- 
tal, again stopped the evacuations, caus- 
ing the National Guard to halt further 
attempts for the day — and to lea\e. 

Now, one of the nurses on Charity's 
9 West was sounding an alarm, alerting 
the HI\' ward and Berggren — an infec- 
tious diseases specialist, an associate 
professor of medicine at Tulane Uni\ersi- 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




ty, and the ward's physician in charge — 
that there was an intruder. 

Berggren jumped up, opened the 
door, and stopped in her tracks, ri\'eted 
b\' the sight of an intense and sweaty 
Marine. He was on edge; someone was 
shouting at him and raking him with 
the beam from a flashlight. He was car- 
rying a gun — and that gun was now 
pointed at Berggren. 

"It was a \'ery big gun," says Berggren. 
And It was the second loaded weapon 
she had come uncomfortably close to in 
under 24 hours. 

Taking a deep breath, Berggren iden- 
tified herself to the young soldier, eased 
her medical identification up for view- 
ing, and explained that staff and 
patients still occupied Charity Hospital. 
Still occupied a facility that had no elec- 
tricity; no working toilets or showers; 
no functioning ventilators, monitors, 
phones, or computers; and little food or 
water. A facility to which the authori- 
ties had sent this Marine to check for 
looters, a facility that he thought was 
e\'acuated of personnel and patients. 

But about 200 patients were still in 
Charity Hospital, including 13 on 
Berggren's ward. And Charity still held 
the doctors, nurses, and other hospital 
staff who had protected and served 
those patients through nearly a week of 
record-setting hell. 

"It was disheartening to learn that 
our message hadn't been received," says 
Berggren of the Marine's misinforma- 
tion on Charity's status, "and startling 
to realize that the authorities didn't 
even realize we were there." 

Berggren had been on duty when the 
hurricane hit over the weekend. Its high 
winds and driving rain had slammed the 
hospital, adding to the tension Berggren 
and her team felt as they worked to 
ensure all the patients were cared for 
and safe. By the time the storm moved 



RIPPLE EFFECT: Far left, a satellite's eye 
v'lev/ of Hurricane Katrina as the Cate- 
gory 4 powerhouse approaches the U.S. 
Gulf Coast on August 29, 2005; left, in 
Katrina's wake, flood>vaters cover much 
of New Orleans, stalling the city and 
forcing residents to navigate their way 
to safety on foot. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN I 37 



TRACKING THE STORM 



^— "^^ 4 



H 




M^: 



out of the city late Monday, the hospital 
was nearing the end of its fuel supply for 
the back up generators. But hopes were 
high that with the storm moving on, 
rested staff would soon be on their way. 

Not so. On Tuesday morning, a look 
out the window told Berggren that reali 
ty had changed o\'ernight. "I felt like I'd 
been slapped in the face," she says. 

Charity was surrounded by water, 
and the water was rising. The basement 
swamped, rendering unusable the stock- 
piles of food and water stored there. The 
generators burned the last of the fuel, 
stemming the building's electrical life line 
and bringing quiet, darkness, and stifhng 
heat. Doctors, nurses, and staff used 
flashlights to na\igate the hallways and 
to check on patients, and they took turns 
manually respiring those on ventilators. 
Care was administered using \'ital signs 
and physical examination skills as guides. 

Throughout their struggle to attend to 
the patients on 9 West, Berggren and 
her remaining staff passed up chances to 
evacuate. The need to fulfill their profes- 
sional commitments kept them at Chari 
ty with their patients. 

"It was important to voice that commit 
ment," says Berggren, "to say aloud that 
we wouldn't leave until our patients left." 
That commitment held strong. Friday 
e\'ening, after rescuers had finally mo\'ed 
the last patients from Charity, the doc 



i\4 



tors, nurses, and staff from 9 West e\-ac- 
uated. They left Charity, but not its spirit. 

"Katrina reminded us that when we 
abandon the poor, the ill, and the disen- 
franchised," Berggren says, "we sow the 
seeds of social chaos. We create a tem- 
plate for manmade disasters." 

Big Charity has yet to reopen. 
Although it stiU stands, the massive steel 
and cement structure may ultimately 
succumb to Katrina. Charity Hospital 
depends on state funds for its operation 
and maintenance, but Louisiana, facing 
Katrina-related revenue losses of up to $3 
billion, may not be able to afford to repair 
it. And e\'en if resources can be found to 
fix all that needs fixing, the building may 
not pass tests for structural integrity. 
Charity Hospital — which, before Katrina, 
was one of the country's oldest, continu- 
ously operating public hospitals — may 
cease to exist. If that happens, Berggren 
and others who practiced or trained 
there, as well as those who sought 
solace within its walls, will need to find 
a new place to sustain them. 

Field and Stream 



When he stepped outside to investigate 
a new site for emergency medical ser- 
vices in Biloxi, Anthony Lamar Mitchell 
had expected a soggy landscape, a scene 
of de.struction and disarray. 




SWEPT AWAY: Left, patients from Charity 
Hospital in New Orleans are evacuated 
by airboat; above, a bust of Jefferson 
Davis, the Confederate president, lies 
amid the remains of Beauvoir, his Biloxi 
home; right, a staircase marks the site of 
a home formerly on Biloxi's coastline. 



He hadn't expected to see fish. 

Although they had already moved 
twice in four days, Mitchell and his col- 
leagues needed a new spot for Keesler 
Air Force Base's emergency department 
and critical care unit. The parking lot was 
the next candidate. This time the units 
would be sheltered by a tent rigged to 
sen-e the needs of nearly a thousand peo- 
ple, a group that included base personnel, 
family members of hospital staff, and 
Biloxi residents who had sought shelter in 
the hospital when Katrina hit their cit}'. 

But to set up the tent, it seemed they 
would first need to contend with the fish. 

"Fish were all over the parking lot," 
says Mitchell, an Air Force Medical 
Corps officer and Keesler Medical Cen- 
ter's assistant medical director for emer- 
gency services. "Even the two large sink- 
holes that had formed in the parking 
area were full of fish, tossed up from the 
Gulf. I knew there had been a big storm 
surge, but I hadn't realized just how big 
until I saw those fish." 

At 30 feet, the storm surge that hit 
Biloxi was the largest e\'er recorded for 
the area. Biloxi, spread as it is along a 
strip of land between the Gulf of Mexico 
and an inlet known as the Back Bay, had 
come close to submerging as Katrina 
dro\'e water o\-er it. 

Katrina's storm surge filled the hospi- 
tal's basement, knocking out power to 



38 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 











the building and flooding the emergency 
room and critical care unit on the 
ground floor. Emergency generators were 
pressed into service and Mitchell and his 
colleagues prepared to mo\'c to the sec- 
ond floor, all the while continuing to 
assist people coming into the emergency 
units, illuminating their patients — and 
their way — with flashlights. At one 
point, Mitchell and a fellow physician 
found themselves trying to determine 
how to treat a woman whose abdominal 
wound had split open. 

"The wound appeared to be septic," 
says Mitchell, "but by flashlight, it was 
difficult to assess. We couldn't ask the 
woman questions; she was a French 
Acadian who spoke no English. We just 
had to wing it. Fortunately, we were 
able to give her antibiotics and intra- 
venous fluids. She improved enough to 
be air-vacced out." 

The makeshift quarters on the second 
floor had to be abandoned two days later 
when power needs again became an 



issue. This time, the group prepared to 
move to the Clinical Research Laborato 
ry, a separate building roughly 150 yards 
from the hospital. That facility had a 
back-up generator that was still crank 
ing. Within ten minutes in the new quar 
ters, Mitchell was scrambling to help a 
man who had suffered a massi\'e myocar- 
dial infarction. Mitchell was able to tap 
the laboratory's electrocardiograph for 
some information on the patient's status, 
but had to rely on basic treatment — 
aspirin, oxygen, and nitrates — to stabi- 
lize the patient. 

"We were tired, dirty, and sweaty, and 
we were continually hauling patients 
somewhere — carrying them around on 
gurneys — ^just to get to quarters that 
would provide some power," says 
Mitchell. "The complete loss of electric- 
ity and water took us by surprise. Most 
of us hadn't envisioned practicing med- 
icine without the usual bells and whis- 
tles. Or of needing to scrounge for 
usable supplies." 



The generator in the laboratory build- 
ing failed after sc\'eral days, so Mitchell 
and colleagues moved to the indepen- 
dently powered field hospital in the 
parking lot. Those quarters, too, pro\'ed 
to be temporary — Hurricane Rita moved 
in and the field hospital folded, pushing 
Mitchell and company back to the some- 
what refurbished laboratory buUding. 

The sense of just how rapidly situa- 
tions can worsen has stayed with 
Mitchell, not only because of his experi- 
ence of packing and unpacking an emer 
gency department several times in only 
a few days, but also because of what he 
observed among the population he 
served during the storm. 

"During Katrina, we were seeing about 
20 people a day under horrendous condi- 
tions," he says. "Even though base person 
nel are a group of relatively healthy mili- 
tary indi\iduals, every day someone else 
would be added to our patient list. Every- 
one, it seemed, was just a day away from 
being sick or injured. Katrina showed us 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



39 



TRACKING THE STORM 




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how important it is to be ready for such 
a demand for medical care." 

Mitchell and his colleagues have since 
moved back to the hospital, to a tUed 
portion of the first floor facility that 
could easUy be scrubbed clean. The 
emergency room, however, is operating 
only at the level of a first-aid station, 
providing xray and basic laboratory ser- 
vices. The hospital as a whole needs to be 
rebuilt; currently it has no inpatient 
facilities. Plans are to have some inpa- 
tient beds and a functioning inpatient 
care unit — and to coax the emergency 
room back to life — by the spring of 2006. 

But Mitchell can't think too much 
about Keesler's facilities these days. 
He's packing once again, responding to 
a different maelstrom. This time, he's 
moving to Iraq. 

Unhoused in Houston 



After several days of being cooped up in 
a friend's home in Houston, of limiting 



his viewing of updates on New Orleans 
to 20-minute, stress-filled glimpses, 
Maurice Sholas could no longer tolerate 
inaction. He got in his car — the very car 
that had allowed him to escape New 
Orleans — and headed for Houston's 
Astrodome. His plan: to volunteer med- 
ical services to New Orleanians who, 
like him, were finding refuge from the 
chaos back home. 

When Sholas arrived at the vast domed 
structure, he entered the new "home" of 
thousands of uprooted people. People 
who had been without so much for so 
long — out of food, water, and faciUties to 
clean or reUe\'e themselves, out of contact 
with friends and relatives. People who had 
waded through the "HazMat gumbo" of 
the New Orleans flood to get to the Super- 
dome, to e\'acuation buses, and, finally, to 
Houston. The people and the conditions 
at the Astrodome formed a yeasty mix 
warmed by the humidity generated by 
exhalations from more than 13,000 peo- 
ple. And that mix had a smell. 



"It was a peculiar stench," says Sholas. 
"I can still recall it." 

Sholas headed for the medical facUity 
for evacuees in the Rehant Astrodome 
complex, an operation housed in a field 
hospital set up in the nearby Rehant 
Arena. Fortunately, Sholas — an assistant 
professor and the director of pediatric 
rehabihtation at Louisiana State Univer- 
sity's Health Sciences Center and its 
affihate. New Orleans Cluldreris Hospi- 
tal — had evacuated with documents ver- 
if)'ing his status as an attending physi- 
cian in Louisiana. He was allowed to join 
the ranks of medical workers. 

During his two weeks as a volunteer, 
Sholas's assignments ranged from trans- 
porting patients to examining babies. 
He remembers one set of twins particu- 
larly well. The mother had spent day 
after sleepless day ferrying the pair 
through the New Orleans flood, and 
protecting and caring for them in the 
chaos of the Superdome. She had strug- 
gled to wedge herself and her tiny 



40 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



charges into space on a bus to Houston 
and, when she arrived at the Astrodome, 
had claimed one cot among the thou 
sands placed inches apart on the floor of 
the facility. She had finally made it to the 
front of the line of patients and had pre^ 
sented the four month-old infants to 
Sholas. He checked them carefully. 

"When I turned to the mother and 
told her the twins were healthy," says 
Sholas, "she just broke down in tears." 

Shortly before the last of the e^■acuees 
were moved to facilities in Arkansas, a 
precaution spurred by the threat of Hur 
ricane Rita, Sholas headed back to 
Louisiana, this time to a couch in his 
uncle's home in Baton Rouge — and work 
at a satellite clinic run by New Orleans 
Children's Hospital. For nearly seven 
weeks, Sholas pitched in to handle the 
influx of pediatric patients from New 
Orleans; many of the children had been 
sundered from parents or guardians. 

Baton Rouge now had the boomtown 
atmosphere that comes when a city's 
population doubles in about 24 hours, 
pushed up by scores of people who had 



headed there from New Orleans. 
Demand for care was intense; dehvery of 
care was difficult. So much was missing 
or unawailable: medical records, medica- 
tions, office space from which to contact 
patients, and exam rooms in which to 
assess their conditions. 

Time was also in short supply for 
Sholas, who had no leisure to sit and 
think or begin to sort out what things 
should be done to inch toward ecjuilibri 
um. For longer than he cared to remem 
ber, Sholas had not received mail and had 
been unable to access his email. He also 
had been unable to get in touch with 
friends, colleagues, and many patients he 
cared for regularly. 

"Like so many others, I have been 
without my support system," he says. 
"I think that's something that has 
made this disaster even greater than it 
appeared to be. After 9/lL people in New 
York could get to friends and neighbors, 
could reach those they cared about by 
telephone only a day or so after the disas 
ter. W'c can't do that, and probably won't 
be able to do that for a long time." 



Although his office remains unusable, 
Sholas has been back at Children's Hos- 
pital since it reopened. Of the dozen or 
so major hospitals in the New Orleans 
area, two have begun operating to a lim- 
ited degree and five, mcluding Chil- 
dren's, are considered fully operational. 

Fully operational may be a matter of 
definition rather than reahty. According 
to Sholas, the doctors at Children's are 
caring for those patients whose families 
have found their way back to New 
Orleans. The hospital, though, is operat- 
ing without significant numbers of its 
other talented workers — many office 
staff and Louisiana State University 
administrators have been furloughed, 
and about half of the hospital's nurses, 
support staff, and maintenance and food 
service staff — many of whom Uved in the 
devastated parts of the city — have not 
returned. Physically, however, Children's 
fared comparatively well in the storm; it 
stands on higher ground. ■ 

Ann Mark Mcnting is associate editor of the 
Harvard Medical Alumni Bulletin. 




HOME AND HEART: Left, a sign on the site of a destroyed Biloxi home signals o new 
start for its owners and a post-Katrino housing push in the region; above, cots fill as 
evacuees from the Superdome in New Orleans find space in Houston's Astrodomes- 
right, a young mother feeds her six-week-old son in the Reliant Center in Houston — 
a quiet moment after days spent shepherding her three children out of their flooded 
Nev/ Orleans neighborhood. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



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SEVERAL RISKS TO PEDIATRIC HEALTH ARE LITERALLY STARING CHILDREN 
IN THE FACE. IT'S TIME TO CALL THE DOCTOR, by Janice O'Leary 



The most important thing wcvc learned. 
So far as children arc concerned, 

Is never never never let 

Them near your television set... 

They sit and stare and stare and sit 

Until theyre hypnotized by it... 
Did you ever wonder exactly what 

This docs to your beloved tot^ 

His brain becomes as soft as cheese 

His powers of thinking rust and freeze 

He cannot think — he only sees! 

-THE OOMPA'LOOMPAS IN CH.\R11E AND THE CHOCOLATE FACTORY 



THE OOMPA'LOOMPAS' CAUTIONARY SONG 

about the hypnotic effects of television on 
children may have seemed alarmist in 
1964 when Charlie and the Chocolate Factory 
was first published, but now its lyrics 
seem almost understated. In Roald Dahl's 
story, television addict Mike Teavee pays 
for his obsession by getting shrunk to the 
size of an actor on a television screen. 
Dahl exaggerates the effects of excessive 
viewing, but for children glued to media 
screens today, the consequences may be 
more insidious and just as hazardous. 

Decades of research have established 
that television and other screen media — 
movies, the Internet, and video games — 
constitute a powerful environmental 
influence on children's health and devel- 
opment, according to the Center on 
Media and Child Health at Children's 
Hospital Boston. American children aged 
8 to 18 spend an average of 6 hours and 21 
minutes daily using media — more time 
than they spend in school or with their 
parents. And the risks of so much time 
spent in thrall to their screens are serious. 






a me 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 43 




edia may play a role in fostering bullying 



More than 2,200 studies have linked 
media use and aggressive behavior. By 
age 18, a child will, on average, have -wit- 
nessed 200,000 acts of violence, includ- 
ing 18,000 murders. Children's pro- 
grams — shows that one would expect to 
be free of violence — average 14 violent 
acts per hour, 8 more than adult pro 
grams. For adolescents, the influence of 
violence in media may e\'en prove fatal: 
the top three causes of death among 15- 
to 19-year-olds all involve accidental or 
intended violence. 

Media use is also a risk factor in obesi- 
ty, eating and sleep disorders, and early 
initiation to smoking, sex, and alcohol. 
New research, much of it conducted in 
affiliation with HMS, shows how media 
can inhibit creativity and cognitive 
development and suggests that media 
may play a role in fostering bullying as 
well as anxiety and attention disorders. 

As often as the science is cited, it is 
ignored. Many parents, too harried to sift 
through research databases, might contin- 
ue to overlook the e\idence unless a trust- 
ed authority — their child's pediatrician — 
emphasizes the dangers of inappropriate 
media content and use. Parents may feel 
powerless in the face of the sheer perva- 
si\'eness of television and computers, but 
physicians are finding new paradigms for 
making media control less remote. 

Media Frenzy 

Like the Oompa-Loompas, Michael 
Rich '91 understands the powerful clutch 
media can have on the mind, especially 
the mind of a child. So well has research 
documented the connection between 
watching violence on television and 
aggressive behavior, he says, that the 
correlation is "stronger than those link- 
ing calcium with bone density and pas- 
sive smoke with lung cancer." 

Rich, a pediatrician and former film- 
maker who worked for two years with 
the famed Japanese director Akira Kuro- 



sawa, directs the Center on Media and 
Child Health. Much of Rich's research 
has focused on the dangers stemming 
from the violence depicted on tele\'ision 
and, more recently, the violence that per- 
meates video games. 

One 2004 study by another group 
compared the physiological responses of 
adults playing four different \ideo games, 
two with storylines and two without. The 
researchers found that story-based \ideo 
games led to significantly more charac- 
ter and game identificarion and increased 
physiological arousal. Other studies have 
documented how such physiological 
responses can lead to aggression. "If you 
watch a \iolent show and a half hour later 
go to a store where someone cuts you in 
line, you're more likely to respond aggres 
sively," Rich says. "Over time, small inci- 
dents accumulate and form patterns of 
violent behavior. What matters is that 
you learn from what you experience." 

And by learning, he means the hard- 
wired kind. "Brain mapping indicates that 
media \iolence is processed along primi- 
ti\'e sunival pathways and stored in long- 
term memory," he says. In other words, we 
embed media \iolence deeply in our 
brains. In work with functional magnetic 
resonance imaging, or fMRI, Rich's team 
has discovered that "the brain regions 
activated when viewing \aolence onscreen 
are the same ones that hght up when 
those suffering from post-traumatic stiess 
disorder reUve their traumas." 

Alvin Poussaint, founder of the Media 
Center at the Judge Baker Children's 
Center and an HMS professor of psychi- 
atry, says that the way children learn 
from television can cause another form of 
lasting harm. "If children watch 'edutain 
ment' — shows that teach through song 
and dance — they begin to associate 
learning with an entertainment format 
and expect that format when they go 
to school," he says. "But teachers aren't 
going to sing and dance for them. So then 
children complain that school is boring. 



Compared to the fast- paced, exciting 
shows the)''re used to on television, it is 
boring. Nothing will meet that standard. 
Television constantly ups the ante." 

Some of the newest research suggests 
that television and the multimedia 
world in which children simultaneously 
watch MTV, listen to iPods, and chat on 
the Internet may be contributing to the 
increase in diagnoses of attention disor- 
ders. Rich believes that fMRI studies on 
attention, which are only now just get- 
ting started, will help establish whether 
a connection exists. 

Certainly, researchers ha\'e found a cor- 
relation between media use and reading. 
"Kids who watch the most tele\ision don't 
do as well in school," says Poussaint. 
"Tele\ision is not the best way to learn; it's 
too passive and noninteracti\'e." A 2003 
study found that toddlers and older chil- 
dren with screen media in their bedrooms 
learned to read later and read less than 
those with no screen media in their 
rooms. The Oompa-Loompas begin to 
seem hke prophets. 

Poussaint adds that 26 percent of 
American children age two and under 
ha\e tele\isions in their rooms. That's a 
quarter of the pediatric population whose 
reading might be delayed and whose par- 
ents cannot monitor their \iewing habits. 
"Kids can operate the remote contiol by 
age two," Poussaint points out, "which is 
especially dangerous with cable channels." 

Preliminary research shows a link 
between hours of tele\ision \iewed and 
bullying behavior. But these studies 
have looked at only the quantity of 
hours watched, rather than the sub- 
stance of those hours. Rich, in his next 
project, plans to examine how program 
content influences bullying and anxiety 
in young viewers. 

Mixed Media Reviewers 

The notion that media have no upside 
has hampered advocacy efforts. Rich 



44 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




^mmamm 



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as v/eW as anxiety and attention disorders. 



says. "Media are not inherently toxic," 
he says, "and adx'ersarial positions 
between research and industry are 
bound to lead to stalemate. We can't 
take a Luddite approach; we can't escape 
media. \\t must learn to live with these 
powerful forces in our li\'es in ways that 
are healthy and safe." 

Rich likes to mull all sides of the pix 
elated Rubik's Cube of media's effects 
on health. "Who knows," he says, "what 
we call inattention today might indeed 
be necessary in the future when 
demands may differ. Maybe we're teach 



ing a different kind of attention, a more 
superficial one that allows a greater 
focus on what's interesting. Maybe it's 
more adaptive; maybe not." 

Like Rich, pediatrician and researcher 
Victor Strasburger '75 believes that 
media — because of their power — can aid 
in child development. "HoUw'ood should 
reahze that regardless of intent," he says, 
"its products ha\'e a pubhc health compo 
nent. Filmmakers could use their medium 
to make kids healthier without losing box 
office sales." While children imitate the 
\iolence on tele\ision or in the mo\ies. 



especially that perpetrated by heroes, 
they also imitate the good behavior they 
witness and positive role models such as 
Mr. Rogers. Strasburger adv'ocates more 
of such prosocial programming. 

John Livingstone '58, a pediatric psy- 
chiatrist at McLean Hospital, an HMS 
assistant professor, and a consultant to 
the television industry, is campaigning 
for PBS to embed emotional hteracy in 
its new programming and for the cable 
industry to embrace health-risk stan- 
dards. "Television shows can model pos- 
itive ways for handling feelings," he says. 



DUMBING DOWN: 
On a tour of Willy 
Wonka's chocolate 
factory, Mike Teavee 
is so enthralled 
with television that 
he ends up shrink- 
ing to the size of 
an actor on the 
television screen. 



CO 




^•v 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



45 



be literate used to mean you could/read and 



ifre 
/I 



f 



"Social learning research shows that 
when children watch likable characters 
struggling with decisionmaking, they 
can learn better impulse control, espe- 
cially when they see the realistic results 
of the choices the characters made." 

The power of prosocial programming 
can be so strong, Livingstone adds, that 
even violent content — when portrayed 
realistically and in the context of out- 
comes — can be beneficial. "If it's handled 
well," he says, "\'iolence with conse- 
quences can promote socially responsible 
behavior. Let's say a show features a gang 
of kids on a street. In one scenario, a gang 
member remarks that a passing kid looks 
like a wimp and says, 'Let's punch him 
out.' The group beats him up." 

"In a better scenario," Livingstone says, 
"the gang member remarks that a passing 



kid looks like a wimp and says, 'Let's 
punch him out.' But this time a hkable 
gang member speaks up against the plan, 
then another and another. Half the group 
takes off in protest. The other half beats 
the boy up and later faces legal and 
parental repercussions. The program 
could retain its dramatic tension while 
modeling a socially acceptable option in 
the teenager's world." 

Poussaint helped create prosocial 
content when he worked as a consul- 
tant to "The Cosby Show" for eight 
years. "I would review scripts to elimi- 
nate any stereotypes or put-down 
humor," he says. "Cosby wanted the 
program to be a positi\'e model for fam- 
ilies. We'd bring up real family issues 
and make them as believable as possi- 
ble. I also critiqued what people would 



eat on the show. If the script called for 
fried pork chops, I'd change it to grilled 
chicken." Even a small change had the 
potential to cause powerful ripples — the 
show reached 60 million viewers. 

Don't Touch That Dial 

Prosocial programming is one solution 
to dealing with the potential dangers of 
media; media Uteracy is another, and one 
that puts power in physicians' and par- 
ents' hands. For Rich, media literacy has 
two components. First parents and 
physicians need to be educated about the 
science. To this end. Rich has developed 
a website that offers a searchable data- 
base of all the multidisciphnary research 
on the health effects of using media. So 
far his team has collected citations for 



46 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



v/r\\e. No>v you must decipher a variety of medio. 



// 



nearly 8,000 studies, already one- eighth 
of which browsers can search onhne. 

"I want to get the science out there," 
Rich says. "An interdisciplinary approach 
will test and enrich each field and any 
future research." He hopes his fellow 
pediatricians especially wiU become reg- 
ular users of the site and, once they know 
the research, will pass on what they've 
learned to their patients' parents. 

The second component to media lit- 
eracy is teaching children to become 
media savvy. Currently, Rich's team at 
Children's Hospital is studying the 
effects of teaching media hteracy to ele- 
mentary school children. Building on 
pre\'ious research that discovered that 
six -month media literacy programs for 
fourth graders resulted in weight loss 
among the children and a 25 percent 
reduction in schoolyard \'iolence, they 
are evaluating whether media-savvy 
children are better able to protect them- 
selves against obesity, substance use, 
and violent beha\'ior. 

In another stud\', published in 2003 by 
a Stanford researcher, third and fourth- 
graders participated in a media hteracy 
program. After one week of "television 
turnoff," they were encouraged to follow 
a seven-hour per week budget. Addi 
tional lessons taught "intelligent view- 
ing." By the end of six months, combined 
average tele\ision and \'ideo game usage 
plummeted from an initial 18 hours per 
week to 10, and the children experienced 
an average body mass index decrease 
of nearly half a point. 

Strasburger, who researches media's 
effects on children and adolescents at the 
University of New Mexico, also wants to 
promote media hteracy, but finds it diffi- 
cult to convince physicians, parents, and 
teachers that the issue should take prior- 
ity. "When I consulted with the National 
Parent Teacher Association," he says, "its 
leaders had a hundred concerns on their 
list, and media literacy was nowhere 



near the top. They wanted to talk about 
obesity, eating disorders, and bullying, 
but didn't realize that media affect all 
those problems. Many parents and 
teachers believe media have a minor 
influence. That might have been true 
when they were growing up, but it sure 
isn't the case now." 

Poussaint adds that parents should 
play an important role. "Parents need to 
watch tele\ision with their children and 
explain what's make beUe\'e," he says. 
"Commercials are especially insidious, 
because children don't begin to under- 
stand the persuasive intent of ads until 
about age eight. Commercials also pit 
children against parents. Television tells 
children a particular candy bar will make 
them happy and, when parents refuse to 
allow it, the children see their parents as 
den)ing them this happiness." 

Strasburger says some of this work 
can be done in school. "We need to 
teach kids skepticism about advertising 
and television programming," he says. 
"They should understand, for example, 
why a commercial or show airs when it 
does. We already have a system in place 
for teaching media literacy: sex and 
drug education programs in schools. 
Both could incorporate media literacy, 
and teachers could take the lead." 

Strasburger knows how difficult a 
demand that is. "Administrators are 
already overwhelmed by state mandates 
for teaching," he says. "But the nature of 
hteracy has changed in the past century. 
To be hterate used to mean you could 
read and write. Now you must decipher 
a variety of media. Our schools ha\'en't 
caught up to the digital age." 

Scars of the Silver Screen 

The entertainment industry and Con- 
gress both point to the ratings system 
as a protective mechanism for child 
viewers. "But studies have shown that 



ratings are often deceptive," says Stras- 
burger. "Parents don't understand rat- 
ings, and kids want to see whatever the 
next level above them is." 

And what children perceive as only 
one level up is often more like two. In 
2000 the Federal Trade Commission 
found that 80 percent of movies rated R 
and 70 percent of video games rated 
M — or mature — for violent content 
were marketed to children under 17. 

To add to parental confusion, movies, 
television shows, and video games all 
have distinct ratings systems, based on 
guidelines created by industry execu- 
tives. Rich, Livingstone, and Poussaint 
have testified before Congress to plead 
for a unified, science-based ratings sys- 
tem. "Few people understand what the 
ratings mean," Rich says. "The current 
system is worse than an imperfect sci- 
ence. Imperfect, yes. Science, no. Every 
network and movie company has differ- 
ent standards, and they're not aimed at 
what's best for children. They're aimed 
at what parents will let their children 
see, which, in changing times, is always 
a moving target." 

Livingstone says that the media exec- 
utives w'ho created the television rat- 
ings in 1996 never developed uniform, 
evidence-based standards; instead, they 
rehed on their own values. He would 
prefer to eliminate ratings and potential 
First Amendment conflicts about free- 
dom of speech by allowing nonprofit 
organizations to select menus of low- 
risk programs and to provide those 
menus on screen for parents, coupled 
with the electronic means to convert 
their televisions to air only those shows 
in their absence. 

The "V-chip was intended to provide 
this kind of high-tech protection, yet 
Poussaint beheves it failed miserably. As 
an advocate for protecting children, his 
center was active in getting the V-chip 
approved at the federal level. "We fought 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



47 




edia cut across every public health concern 



hard for it," he says, "but people don't use 
it. Many parents don't even know that 
since January 2000 all new television sets 
larger than 13 inches have a V chip they 
can use to block certain channels." 

Poussaint speculates that the V-chip 
may be a failure not just because of igno 
ranee, but also because of a skewed rat 
ings system. MTV, which is rated TV- 14, 
demonstrates the problem. "Many par- 
ents let TV'14 shows through the fUter, 
but channels like MTV are not always 
healthy for teens to watch," he says. "Rap 
N'ideos especially are often misogynistic, 
encouraging men to mistreat women. 
Just when social development begins, 
social relations become problematic." 

One of the necessary conditions for 
the industry to accept any health-based 
system, Li\'ingstone says, is that physi 
cians must know and support the scien 
tific standards. "First the medical com- 
munity needs to be clear that personal, 
value 'based reactions to media content 
differ from evidence-based risk factors," 
he says, "or the industry will continue to 
divide and spin us. Industry believes 
any standards constrain, but health 
standards actually liberate because they 
consider context and are unbiased. The 
market is there for low-risk and health- 
promoting programs. PBS and cable 
could lead the way." 

Li\ingstone emphasizes that asking 
the industry, excluding the nonprofit sec- 
tor, to behave responsibly leads nowhere. 
And he knows from experience. After the 
V'cfiip was implemented he consulted at 
MTV, ad\'ising executives to wea\'e scien- 
tific standards into programming. 

"When I suggested changes for health 
reasons," he says, "the executives told me 
they had to keep profits intact. They used 
my input when it happened to do\'etail 
with their legal mandates — eliminating 
gratuitous sexual images and dangerous 
imitative behavior, such as suicide and 
drug use — and their personal values." 



"Asking networks to behave respon- 
sibly is the wrong paradigm," Li\'ing- 
stone says, "because they must hew to 
the bottom line. The entertainment 
industry will embrace health if it has 
other reasons for doing so besides altru- 
istic ones. If there are dollars on the 
other side of it, industry executives will 
want to do it. They don't need to assess 
shows. They just need to enable parents 
to make informed, health-based, and 
personal value choices at home. If par- 
ents can choose healthy, safe programs 
for their children, they will filter out the 
other shows. That will drive the change 
in programming. Creative professionals 
will want to make more shows that can 
pass through the filter." 

"We're up against an industry where 
money usually comes first," Poussaint 
adds. "The impact on children is often 
secondary." If it's considered at all. 

The Golden Ticket 

Studies have suggested that 10 to 30 
percent of violence in society can be 
chalked up to the impact of media vio- 
lence, says Strasburger. "That's a nice 
big chunk we can do something about." 
And by "we," he means doctors. 

Until improx'ed high-tech approaches 
go h\'e, physicians can help children de\'el- 
op healthy media habits through a lo\\'- 
tech approach: conversation. "Physicians 
aren't saying enough to parents," Rich 
says. "We need to educate doctors to 
educate parents that media matter." He 
adcis that many parents don't know that 
the American Academy of Pediatrics has 
established guidelines that recommend 
no televisions, video games, or Internet 
access in children's bedrooms; no screen 
media for children under two; and no 
more than two hours of educational tele 
\dsion a day for children older than two. 

If most parents don't know the recom- 
mendations, they certainly don't know 



the reasoning behind them. "In the first 
18 to 24 months of life, the brain is devel- 
oping rapidly, primarily in response to 
en\'ironmental stimuli," Strasburger says. 
"Stimuh that optimize the development 
of brain architecture include personal 
interactions, motor skiUs practice, and 
problem-solving activities. And the best 
way to teach these skills is not through 
screen media." 

"Physicians need to encourage par- 
ents to interact with kids while watch- 
ing television," Poussaint says. "Parents 
come home from work and turn on the 
news without thinking. Kids see images 
of the war in Iraq without anyone 
addressing their fears." 

"What disturbs me most is that my 
fellow pediatricians don't seem to get it," 
Strasburger says. "Media cut across every 
pubhc health concern that they have for 
their patients: obesity, eating disorders, 
attention disorders, violence, sex, and 
drug use. Yet while they worry about 
obesity, pediatricians dorit realize the 
significance of media. The reaht)' is that 
media play a huge role in determining if a 
child will become o\'er weight; obesit)' 
has been linked conclusively with tele\'i- 
sion ads and time spent in front of a 
screen." Strasburger discovered that his 
own heavier patients watch three to five 
hours of television a day. When they take 
him up on his suggestion to adopt a dog 
and walk it one hour each day, they lose 
significant weight. 

But change can happen only when 
doctors perceive content and misuse 
of media as a root health problem, 
Strasburger says. "I have several theo- 
ries about why pediatricians put media 
at the bottom of their lists," he says. 
"They may not watch much television 
themseh'es. They may know television 
from a kinder, gentler era. Or possibly 
they may be so focused on helmet use, 
immunizations, and developmental 
milestones they can't squeeze another 



48 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



that pediatricians have for their patients. 



// 




discussion into an examination. Of 
course, they may just be tired of being 
browbeaten by academics like me." 

Parents, who themselves are likely 
desensitized to violence through media, 
may also feel browbeaten — by the chal- 
lenges of careers, caretaking, and com- 
muting. But counsel from a trusted 
source — a pediatrician — could make a 
big difference, Strasburger says. "Giving 
such advice can take less than a minute. 
Ask just two questions; How much 
screen time does your child have per day? 
And, is there a television set in your 
child's bedroom?" 

Li\'ingstone urges primary care physi 
cians to become conversant enough with 
the risk factors of media content to feel 
confident speaking to parents about 
those risks. One way they might do this. 
Rich suggests, is through resources 
developed at his center, in addition to the 
searchable online database. "Physicians 
can come to us," he says. "We're de\'elop- 
ing a series of diagnostic guidelines and 
therapeutic interventions that physi- 
cians can use in the office to evaluate 
whether their patients are suffering from 
an overexposure to media." 

Livingstone agrees that pediatricians 
should broaden the definition of pedi- 
atric health care by taking a "media his- 
tory." "By asking a few questions," he 
says, "pediatricians communicate their 
belief in the child's mind and in our 
power to help develop that mind." 

And those few questions just might 
make the difference between a child hav- 
ing a brain that, as the Oompa Loompas 
warn, becomes soft as cheese, or one that 
develops healthy and sharp. ■ 

Janice O'Lcary is assistant editor of the 
Harvard Medical Alumni Bulletin. 

Visit w'W'w.cmch.tv/research/searchcitations.asp 
to access the research database of the Center on 
Media and Child Health. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



49 



A FEW GOOD WOMEN: Martha Bears Rich (bottom row, 
second from right) was one of only 26 of the original 90 
class members to complete an arduous nursing program. 




50 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



hy Martha Bears Rich 



I COULD STILL SMELL THE BURNED FLESH, 

decades after the Cocoanut Grove fire. It Training 

was a day when I accompanied a group of at Harvard 

high school students on a field trip to hospitals 

Massachusetts General Hospital. Although during World 

I knew nothing stronger than the scent of War II goVO 

cleaning products was lingering in the air, one student 

the moment I entered the old corridor, nurse Q crash 

I felt overwhelmed. The mere sight of the COUfSe in the 

brick walls brought back memories of the fast-paced 

awful stench that had permeated the realities of 

hallway, where corpses were laid out so clinical CO re. 
thickly there was barely room to walk. 





^ 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 51 





..ff^: 



m 






IN THE LINE OF FIRE: 
Within several 
moments, the hun- 
dreds of revelers 
jommed into the 
Cocoanut Grove 
^ere thrown into 
a panic as a roar- 
ing mass of flame 
swept through the 
club with explo- 
sive speed. 



On November 28, 1942, the date of the fire, I wasn't 
much older than a high school student myself. That 
next morning the director of nursing at Simmons 
College told our class of student nurses that Massa- 
chusetts General Hospital was asking everyone with 
experience on the wards to help with the Cocoanut 
Grove victims, casualties of a fire that would claim 
nearly 500 lives. 

I \isited the Cocoanut Gro\'e only once when it 
was in business. Ironically, I still ha\'e a matchbook 
from the famous Boston nightclub. When news of 
the fire broke, I recalled the club's dance floor, which 
had room only for a few couples, and its garish, arti- 
ficial palm trees — later identified as possible acceler- 
ants to the fast-moving blaze. 

I had already heard about the disaster on the 
radio but had little idea of what to expect when I 
arrived at the hospital. Although the se\ere short- 
age of medical personnel caused by the demands of 
World War II would eventually allow me to gain a 
great deal of firsthand experience, as of that night I 
had been "capped" — ceremonially initiated into the 
nursing profession — for only a few months. I hadn't 
had much opportunity to work in mass trauma sit- 
uations, although I had certainly heard many sto- 
ries. My favorite aunt, who inspired me to enter the 



nursing profession, took care of military casualties 
during World War I. She told me how the wound- 
ed were crowded so closely together that she had to 
step on the rungs of their cots to get from one side 
of the ward to the other. 

I couldn't have predicted that, like my aunt, I, too, 
would see my nursing career coincide with a world 
war. But for me, the war felt distant, even though my 
fiance, brother, and cousins were all on the frontlines. 
The Cocoanut Gro\'e tragedy, by contrast, I experi- 
enced acutely. E\'en though I wasn't assigned to the 
emergency room, I witnessed the agony. The football 
teams of Boston College and Holy Cross had engaged 
in their intense traditional rivalry that afternoon, 
drawing a huge, youthful crowd into town and into the 
club that night, and many of the \ictims were my age. 

By the time I arrived at the hospital, workers had 
already cleared an entire floor of inpatients, adhering 
to emergency procedures that were in place because 
of the war, to make way for the injured. The first task 
was to sort the living from the dead. Stepping gin- 
gerly around the bodies, doctors and triage nurses 
looked for signs of life. 

The corpses were carried to the brick corridor, 
which ser\'ed as a morgue for the first couple of days 
after the disaster. I traversed that corridor each 



52 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 



' the time I arrived, workers had aire 

cleared an entire floor of inpati^ 

rst task was to sort the living from d 



morning, and ne\'er could get away from the stench 
of charred flesh and hair and fabric. Even our uni- 
forms seemed to reek of it. 

Out of the Ashes 



1 continued to work at the General for a few days fol- 
lowing the fire and returned a month later for my 
scheduled year of clinical experience. By then some 
of the fire victims had been transferred to the regular 
wards. To treat these patients we slathered their burns 
with boric acid ointment and applied sterile gauze 
bandages and pressure bandages over the gauze. The 
treatment seemed revolutionary at the time. Physicians 
would apply lessons learned from the Cocoanut Gro\'e 
experience to their care of soldiers burned in the bat 
des of the ongoing war. But years later, it became clear 
that many people with major burns had absorbed a 
great deal of boric acid and were experiencing a range 
of health problems, so that approach was abandoned. 

One of the patients on the wards where I worked 
was Dotty Myles, a teenage \'Ocalist with Mickey 
.Alpert's band, which had been playing the club on 
the night of the fire. Badly burned on her face and 
hands, she had been left for dead on the sidewalk. 
But she somehow managed to drag herself to an 
ambulance already crowded with \ictims. She was 
the only one of them still alive by the time the ambu- 
lance reached its destination. 

Enduring months of skin grafts. Dotty used the 
rings on her bed curtains as rosary beads. When the 
burns on her face healed to the point where it was 
safe to cover them, she would apply makeup to mask 
her scars, don a pretty bed jacket, and tie her hair 
back with ribbon, a ritual made private by the cur 
tains she would ask the nurses to pull around her 
bed. When she had recovered enough to walk 
around, she'd visit the other burn patients, singing 
softly to entertain them and raise their morale. 

Life in the Ward Zone 



My nurse's training was a serious business with 
few allowances made for youthful impetuousness. 



After beginning the program at Simmons College in 
September 1940, 1 tramed at several Harvard hospi- 
tals. The United States had entered World War II 
during my sophomore year, and the war was still on 
when I graduated. 

The mentality of a nation at war was reflected in 
the boot- camp like atmosphere we endured as nurs- 
es-in-training. We had a strong sense of being on the 
home front, although we rarely saw servicemen 
because they received treatment at military hospi- 
tals. We worked 12-hour days in the hospitals, with 
no breaks. When we got off duty at seven in the 
evening, we attended classes for another few hours. 
We fell into bed exhausted, but then had to be back 
on the wards early the next morning. If someone 
failed to relieve us we couldn't go off duty — and 
often no one relieved us. 

With the war on, many experienced nurses were 
in the service, so our training turned out to be inten- 
sive. There were many times when I was the only 
nurse for a 40-bed ward. Those of us who made it 
through our training emerged with the skills and 
confidence that came from being thrown into clini 
cal experiences for two solid years, day and night. 
The discipline we gained also helped us deal with 
the many privations of the war era. 

Chief among those privations was food. We were 
required to turn our ration books in to the hospital, 
so our stamps could be pooled for everyone. The 
food shortage meant that the hospital fare was just 
dreadful. Every Sunday the General served a dish 
listed as "creamed chicken." One chicken, it 
seemed, was used to feed the entire hospital, both 
staff and patients. We never glimpsed the actual 
chicken; we just received a sort of greasy gravy 
slathered on toast. 

If we were lucky enough to get a 15-minute break 
while on night duty, we could descend to the cafete- 
ria for "tea," which meant tea or coffee with slices of 
cold, dry toast spread with uncolored margarine, 
which looked and tasted like lard. That's all we ever 
had to eat at night; we never received a proper meal. 

One of my patients at the General was a fruit ven- 
dor from the North End. When a visiting relative 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



53 



' le strict expectations were also 

(reflected in the fastidious attention 
superiors paid to our appearances. 



brought some bananas, my patient gave me one. It 
was just a regular, ripe banana, but bananas were 
like gold. I took it back to my dorm room and shared 
it with all my off-duty classmates: seven of us clus- 
tered around one banana, savoring each morsel. 

I suspect our inadequate rations contributed to our 
feeling so dog-tired all the time. My fiance's father, a 
dentist, once took a look at my teeth and exclaimed, 
"Someone's been starving you!" N4y molars were 
decaying for no reason other than malnutrition. 

In January 1944 we went from the General to Chil- 
dren's Hospital. During our first weekend there they 
served us each a quarter of a chicken. I remember sit- 
ting at the cafeteria table with my friends, each of us 
just staring at the plate before us. It was like heaven; 
we hadn't received that much food at one meal in a 
year. Children's Hospital pro\ided us with nutritious 
meals and it showed, because although we were 
tired, we weren't as exhausted as we had been. 

Spit and Polish 

The tough regimen extended beyond dietary restric- 
tions. Ours was a military- style discipline; we did 
what we were told. If we erred we heard about it 
immediately, as we learned not long after arri\ing at 
the Peter Bent Brigham Hospital for our first few 
months of clinical work. The utility room had a 
"copper hopper," a long tube into which we emptied 
bedpans. No one ever clarified its purpose; students 
were expected somehow to know already what it 
was. That same utility room had a laundry chute. So, 
for several days, one of my classmates unwittingly 
emptied bedpans down the laundry chute. When 
her error was discovered, she was severely chastised. 
But no one had explained the difference to her. 

The strict expectations were also reflected in the 
fastidious attention our superiors paid to our appear- 
ances. We were told exactly what to wear and how to 
wear it, and our clothing was inspected frequently. 
If our shoes weren't clean, we were reprimanded. 

E\'ery school had a distincti\'e uniform, which dif- 
fered for students and graduates. Our student uni- 
form was a below-the-knee, white-collared blue 
dress worn underneath a white apron. Our graduate 



white uniform had 30 tiny buttons that ran down 
one side and across the waist; yet more buttons ran 
dowTi the long, pleated sleeves. Pushing the buttons 
through all those tiny openings took forever, so we 
quickly learned how many we could lea\'e buttoned 
and still manage to shp on the uniform. We also 
wore a plain white cap with a spht in the front. 

We didn't complain much about these inconve- 
niences, though, because we thought the Simmons 
uniform was the best one. We laughed at some of the 
others, which we thought looked hideous, particular- 
ly the student uniform for the General's nursing 
school; a long black-and-white check dress with a 
white apron and a cap shaped like a coffin with a frill 
around it. We tried to bend the rules by pinning our 
caps in a way that flattered our faces. But if we wore 
them too far back, too far to one side, or not folded 
just right, our supervisor would bark, "Fix that cap!" 

School Ties 



Spit and polish sometimes went too far. One night 
at the General, I was assigned to the operating 
room, where we were about to do some vein liga- 
tions. But a terrible train accident occurred at the 
North Station yard, and a slew of ambulances 
brought in a large number of patients, some with 
their legs half-severed. I didn't get off duty until 
nearly nine in the morning, having gone on duty at 
a quarter to eleven the night before. I stumbled 
into bed and had just fallen asleep when the 
housemother of the nurses' dormitory started 
pounding on the door. "Wake up, put your uni- 
form on, and get back on the floor, immediately!" 
When I asked why, she snapped, "Don't ask. Just 
go!" So I dressed and returned upstairs, where the 
operating room supervisor chewed me out because 
I hadn't dusted one piece of equipment. 

I explained that nearly 30 serious injuries had 
been admitted during the night but she would have 
none of it. I was supposed to dust, and she didn't 
care if I had to stay there until noon. I should ha\-e 
taken care of it before I left. 

I was furious. When she finally let me go, I 
marched downstairs and took the streetcar up to 



54 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




Simmons. The head there was Helen Wood, a prim 
maiden lady in her sixties. Her hair was always 
perfectly coifed and she wore neat dresses with a 
brooch at the throat. She was extremely strict but 
kind, too. I now stomped into Miss Wood's office 
and announced, "I'm quitting!" When I explained 
my reason, she drew herself up, put on her coat, 
stabbed a few hatpins into her hat, and strode out 
with me, muttering as we left, "They wouldn't 
have done this to one of their own students!" 

I ne\er found out what Miss Wood said to the OR 
supenisor, but she never treated me that way again. 
Miss Wood was strict, but she al\\ays backed us up. 

Division of Labor 



Yet there were certain ironclad rules of authority 
we dared not break. If a doctor entered a room, for 
example, we stood up and remained standing until 
he left. We ne\er spoke to the doctors, we were 
never allowed to ask questions, and we never, ever 
sat with them in the cafeteria. I remember eating 
my cold toast alone on night duty once when a 
young intern joined me at the table. When I ner- 
vously told him I couldn't sit with him, he replied, 
"That's ridiculous. I just want to talk to somebody." 
A supervisor strode over and reprimanded me: 
"What do you mean by sitting here with one of the 
doctors? Get back up to your ward!" 



Student nurses on rounds could do no more 
than follow and listen. Sometimes if the doctor 
was interested in the case, we would learn. But 
others would simply pat the patient on the shoul 
der, say, "Oh hello, Mrs, Brown, how are you 
today?" and leave, and that would be it. In those 
instances, we w^ouldn't learn anything — and nei- 
ther would the patient. 

The medical students would occasionally pipe 
up, but they were almost as beaten down as we 
were in those days. They worked long, punishing 
hours. And the interns weren't much better off. 
They worked day and night, straight through, 
grabbing an hour of sleep here and there when 
they could. Patients probably died because the 
doctors were delirious with fatigue. 

Fortunately, times have changed, and the young 
women and men training as nurses at the various 
Harvard hospitals are no longer subject to what 
now seems to have been a draconian workplace 
culture. Those of us who lived through that era, 
though, will never forget its lessons. We were 
extremely well prepared for whatever branch of 
nursing became our life's work. ■ 

Martha Bears Rich served as a school nurse at Sharon 
High School for 21 years before retiring in 1986. She was a 
founder and the first president of the Massachusetts School 
Nurse Organization. 



TRAINING DAZE: 
Nursing students 
would wrork 12- 
hour shifts v/lthout 
a break — end 
then spend hours 
in the classroom. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



55 



ATJIMNTIS PROFIT. K 



THOMAS J. GILL IV '90 



Stepping Up to the Plate 




RTHOPEDIC SURGEON THOMAS J. 

Gill IV '90 admits that as a 
boy he didn't always appreci- 
ate the privilege of going on 
grand rounds with his physician father 
on Saturdays. "Meeting visiting Nobel 
Prize winners didn't faze me," he says. "I 
went only for the cheeseburger and fries 
Dad promised." 

But Gill's three children have a different 
experience when they accompany their 
father to work on Saturdays: they enjoy 
their burgers while sitting beside the 
dugout in Fenway Park, as Gill watches his 
patients on the field. These patients are 
among his newest; in the spring of 2005, 
the Boston Red Sox recruited him as med- 
ical director. And to GUI, an a\id sports fan, 
the appointment felt lil<e hitting one out of 
the park. 

For many years GiU stoked his enthusi- 
asm for sports by working as an assistant 
team physician for the New Fngland Patri- 
ots and the Boston Bruins. Those roles 
taught him a new way to take in a game. 
Now when GiU watches the Sox, or any of 
his teams, he's no longer just a fan. He's not 
just concerned with whether Manny 
Ramirez caught the pop fly or Curt 
Sc hillin g struck out a batter. "My eyes 
hardly ever follow the ball," he says. 
"Instead I pay attention to the player's leg 
position on a slide. I watch the pitcher's 
arm for any lagging motion or signs he's 
hurting or getting tired." 

From the sidelines at GUlette Stadium, he 
tracks the Patriots' faces rather than the 
pigskin. "Fvery play in football involves a 
contact," he says. "The ball goes into play 
and then 350-pound guys slam into each 
other. I gauge how quickly the quarterback 
gets up. Does he seem dazed? You get to 
know the players and study their faces for 
signs they're hurt, even when they insist 
they're okay" 

Like any team physician. Gill applies 
splints and casts, tends to rotator cuffs, 
pumps fluids into players with colds. 



and performs surgery when necessary. 
But he's also trying to do his job in a way 
that's surprisingly revolutionary in 
sports medicine. "The Red Sox take a 
different approach than other teams do," 
he said. "We don't just practice reactive 
medicine; we stri\'e to prevent injury 
and sickness whenever possible. During 
our preseason physical exams, we screen 
players and coaches for cholesterol, 
heart disease, asthma, diabetes. If we 
can help them take care of such prob- 
lems then, it means less missed time on 
the field — and healthier patients." 
With frequent trades to new teams in 




THE BEST DEFENSE: Gill helps Patriots 
quarterback Tom Brady ofif the field 
after a tough sack. 



new cities, most players have never 
received longitudinal health care or had 
the same doctor for more than a few years. 
To remedy this lapse, GiU and his staff take 
long histories of each player and often of 
their famUy members. "Most players don't 
have primary-care doctors, and neither 
does the coaching staff," he says. "Some 
coaches are 50 years old and their h\'es as 
ballplayers are catching up with them." 



He points out that the baseball lifestyle 
is especially tough. "After six v\-eeks of 
spring training, the team plays about 160 
regular games, and then, with luck, come 
the playoffs. Players fly nearly e\er)' week 
during the season, sometimes multiple 
times," he says. "Late games mean httle 
sleep. Nutrition suffers as they grab fast 
food or candy bars, which are always 
around the dugout or clubhouse." 

Working in the professional sports 
industry can be tough on any doctor who 
forgets he or she is a physician first, GiU 
adds. "The politics for team doctors are 
often unreal," he says. Some teams pres- 
sure physicians into unethical practices, 
such as not disclosing injuries or numbing 
injuries so players can return to games 
before they're healed. 

"But there is only one t)'pe of team 
physician to be — a true physician," Gills 
says. "The second you treat players differ- 
ently from regular patients, you start to 
deliver poor care and you lose their trust. 
You hope medicine can be abo\'e pro 
sports and business. I don't let either 
influence my medical decisions. We're 
fortunate in Boston to ha\'e teams with 
highly ethical owners who want the best 
for their players. They give us just one dic- 
tum — do whatever it takes to provide 
their organizations with the best medical 
care in the league." 

Extra Innings 

The truly revolutionary aspect of GUI's 
work is his research in biomechanics and 
tissue engineering at Massachusetts Gen- 
eral Hospital, work that played a major 
role in why the Red Sox chose him as team 
physician. In the MGH Bioengineering 
Laboratory, for example, GUI does three- 
dimensional imaging of how joints per- 
form. After a knee reconstruction, he can 
determine whether the joint is beginning 
to function normally. These studies have 
changed the way certain knee Ugament 
reconstructions are now done. 

"When Curt Schilling's ankle was 
reinjured in the spring of 2005," Gill 
says, "my staff and I could quantify his 
strength, determine how normal his gait 
was, and judge his recovery more accu- 
rately than anyone had done before. We 



56 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2005 




■'My eyes hardly ever follow the ball. Instead I 
pay attention to the player's leg position on a 
slide. I watch the pitcher's arm for any lagging.' 



collaborated with the MGH Biomotion 
Laboratory to get data on this type of 
injury. That simply hadn't ever been done 
for an in season athlete." Gill compiled a 
kinematic profile for Schilling's entire 
body — a study of his motions, excluding 
the forces of mass and gravity — and com 
bined that information with calculations 
of the forces exerted on Schilling's skele- 
ton by his gait. With those data Gill and 
the staff from the biomotion laboratory 
assembled a three dimensional picture of 
each body segment during balance tests 
and pitching simulations. Analysis of 
those reconstructions helped him pre- 
scribe the most appropriate rehabilita' 
tion exercises and orthoses to get 
Schilling back on the mound. 

Gill tries to avoid full-knee replace 
ments, preferring instead to put another 
research project to use; regrowing cartilage 
using a microfracture technique. "Because 
articular cartilage has no blood vessels or 
nerve tissue, the body can't heal defects to 
cartilage on its own," Gill says. He can bore 



into the subchondral bone in the knee, 
however, and find undifferentiated cells, 
which, when subjected to limited weight- 
bearing stress and continuous passive 
motion, can differentiate to form cartilagi- 
nous tissue, "heaUng" the defects by thick- 
ening the tissue. 

"I believe the future of arthritis therapy 
lies in biologic treatments for cartilage 
regeneration," GUI says, "rather than total 
joint arthroplasty. At Mass General's 
Laboratory for Musculoskeletal Tissue 
Engineering, we create gels from cell- 
seeded collagen to resurface joints 
damaged by trauma or osteoarthritis." 

Home Team Advantage 

In addition to his team doctoring and 
research. Gill maintains a full practice at 
Massachusetts General Hospital, where 
he performed 600 surgeries last year and 
sees 125 patients a week. He also directs 
the MGH Sports Medicine Fellowship 
program and the orthopedic clerkships. 



Gill knows he couldn't maintain his 
practice, attend to his research, and doctor 
three teams without talented physicians 
by his side. He's grateful for his staff, espe- 
cially his father, Thomas J. Gill III '57, who 
helps run his research team when he has to 
attend an out of-town Patriots game. 

Ha\ing his father work for him reverses 
past roles: Gill cleaned rat cages in his 
father's immunology laboratory at the 
Uni\'ersity of Pittsburgh for $4.50 an hour 
as a teenager. "My dad is the smartest guy 
I've ever met," he says. "It isn't easy, but I've 
always tried to live up to the standard he 
and my mother set for me." So much so 
that Gill followed his father into medicine, 
although they chose different specialties. 

He didn't follow his father onto the 
gridiron, however. "My father played 
football in college," he says. "And because 
of the injuries he sustained, he discour- 
aged me from playing the game." So base 
ball became a passion. 

And in the younger Gill's household, as 
in the homes of many orthopedic sur- 
geons, bunk beds are banned, and skiing 
and football are discouraged. But baseball 
and hockey are revered. 

Gill says his son, Ty, has learned a 
great deal from attending so many pro- 
fessional games at his father's side. "We 
like to discuss what kind of pitch 
should be thrown, or when a pitcher 
should come out of the game. I can see 
the effect when I go to his Little League 
games, because he plays in a very smart 
way. It's the same with hockey, where he 
now makes no-look drop passes or can 
fake out a defender, because that's what 
he has seen the Bruins do." 

Although it may seem incongruent to 
let his son play hockey — a sport known 
for its roughness — but not football, Gill 
says his specialty has shown him the dif 
ferences. "Having taken care of football 
and hockey players for a long time now," 
he says, "I see that football has a higher 
incidence of what I would classify as 
severe or catastrophic injuries. Ultimately, 
they can play what they want — but not 
without a little fatherly input first." Such 
as work hard and do what you love. ■ 

Janice O'Lcary is assistant editor of the 
Harvard Medical Alumni Bulletin. 



AUTUMN 2005 • HARVARD MEDICAL ALUMNI BULLETIN 



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